LER 95-024-00:on 950911,determined Fuel Handling Bldg Low Differential Pressure Surveillance Testing Did Not Ensure Compliance W/Ts Requirements.Caused by Inadequate Design Basis Info.Fuel Handling Bldg ChangedML18101B042 |
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Site: |
Salem ![PSEG icon.png](/w/images/c/cc/PSEG_icon.png) |
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Issue date: |
09/11/1995 |
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From: |
ZARECHNAK A Public Service Enterprise Group |
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To: |
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Shared Package |
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ML18101B041 |
List: |
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References |
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LER-95-024, LER-95-24, NUDOCS 9510160164 |
Download: ML18101B042 (10) |
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Similar Documents at Salem |
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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML18107A5031999-08-26026 August 1999 LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr ML18107A4691999-07-28028 July 1999 LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr ML18107A4441999-07-0606 July 1999 LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr ML18107A4211999-07-0202 July 1999 LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr ML18107A4321999-07-0101 July 1999 LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr ML18107A4331999-07-0101 July 1999 LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr ML18107A3951999-06-17017 June 1999 LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr ML18107A3661999-06-0909 June 1999 LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr ML18107A3551999-06-0202 June 1999 LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr ML18107A3541999-06-0101 June 1999 LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr ML18107A2931999-05-12012 May 1999 LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr ML18107A2781999-05-10010 May 1999 LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr ML18107A2791999-05-0404 May 1999 LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr ML18107A2741999-05-0303 May 1999 LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr ML18107A2351999-04-23023 April 1999 LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr ML18106B1471999-03-29029 March 1999 LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr ML18106B0701999-02-16016 February 1999 LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr ML18106B0491999-01-28028 January 1999 LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr ML18106B0401999-01-18018 January 1999 LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr ML18106B0081998-12-24024 December 1998 LER 97-001-01:on 970215,failure to Perform TS Surveillance of Component Cooling Water Sys Check Valves Occurred.Caused by Inadequate Communication Between EOP Group & IST Reviewers.Procedure Revised.With 981224 Ltr ML18106B0021998-12-17017 December 1998 LER 98-015-01:on 980924,improper Installation of Test Equipment to RPS Occurred.Caused by Inadequate 10CFR50.59 Applicability Reviews During Past Revs.Revised Procedures. with 981217 Ltr ML18106A9551998-11-0303 November 1998 LER 96-013-01:on 960711,concluded That Current Gain & Bias Settings Had Rendered Overtemperature Delta Temp Protection Channels Inoperable.Caused by Scaling Error.Licensee Will Revise Scaling Calculations.With 981105 Ltr ML18106A9451998-10-30030 October 1998 LER 97-004-01:on 970408,failure to Comply with TS Action Statement,Dg Start & Inadequate Surveillance Testing,Was Noted.Caused by Inadequate Tracking of Inoperable Equipment. Discussed Event & Lessons Learned.With 981022 Ltr ML18106A9491998-10-22022 October 1998 LER 98-015-00:on 980924,identified Improper Installation of Test Equipment to Rps.Cause Indeterminate.Procedures for Installation of Test Equipment for Collection of State Point Data Were Placed on Administrative Hold.With 981022 Ltr ML18106A9301998-10-21021 October 1998 LER 98-014-00:on 980725,noted Improper Calibr of Liquid Radwaste Effluent Line Radiation Monitor.Caused by Inattention to Detail by Maint Personnel.Channel Calibr Was Successfully Performed on 1R18 on 980821.With 981019 Ltr ML18106A9071998-10-0101 October 1998 LER 98-014-00:on 980918,discovered That Fire Barrier Matl for HVAC Ducts Does Not Meet Required Level of Fire Resistance.Cause Indeterminate.Established Appropriate Compensatory Actions for Fire Barriers.With 981001 Ltr ML18106A8951998-09-28028 September 1998 LER 98-012-01:on 980725,noted That Afs Was Operated with Less than Required Number of Operable AFW Pumps.Caused by Improper Procedure Implementation.Runout Protection Pressure Device for 22 AFW Pumps Was Returned to Svc.With 980928 Ltr ML18106A8821998-09-21021 September 1998 LER 98-013-00:on 980820,noted Surveillance of Containment Penetration Overcurrent Protection Devices Missed.Caused by Human Error.Satisfactorily Tested Apprpriate Breakers & Disciplined Involved Personnel.With 980921 Ltr ML18106A8791998-09-16016 September 1998 LER 96-006-01:on 960717,determined That non-radioactive Liquid Basin Radwaste Monitor Inoperable During Low Head Conditions.Caused by Inadequate Design Change Package.Design Change 1EC3663-01 Has Been Installed.With 980916 Ltr ML18106A8801998-09-0808 September 1998 LER 98-013-00:on 980806,operation with TS Required Equipment OOS Was Noted.Caused by Human Error.Reviewed Processes & Practices Re Safety Sys Status Control,Procedure Rev & Extra Training.With 980908 Ltr ML18106A8531998-08-27027 August 1998 LER 98-007-00:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Cause of Event Has Not Yet Been Determined.Assembled Root Cause Team & Replaced Affected tubing.W/980827 Ltr ML18106A8521998-08-27027 August 1998 LER 98-011-00:on 980803,ESFA During a 4KV Automatic Transfer Test Was Noted.Caused by Premature Release of Control Console Pushbutton Due to Inadequate Procedural Step.Revised procedure.W/980827 Ltr ML18106A8421998-08-24024 August 1998 LER 98-012-00:on 980725,discovered That Plant Had Operated in Modes 1 & 2 w/twenty-two AFW Pumps Inoperable.Caused by Failure to Restore Pump Runout Protection Pressure Device to Svc.Returned Subject Device to svc.W/980824 Ltr ML18106A8431998-08-24024 August 1998 LER 98-009-00:on 980810,failure to Post Continuous Firewatch as Required by Fire Protection Plan Noted.Caused by Failure to Recognize Concurrent Conditions.Continuous Firewatch Was Posted Immediately & Repaired Smoke detectors.W/980824 Ltr ML18106A8141998-08-13013 August 1998 LER 98-010-00:on 980714,determined That Leakage from Boron Injection Tank Exceeded Max Allowable ECCS Leakage from Sources Outside Containment.Caused by Leaking 2SJ404 Manual Sample valve.2SJ404 Valve repaired.W/980813 Ltr ML18106A8201998-08-13013 August 1998 LER 98-012-00:on 980715,potential to Exceed Rating of Piping Due to Isolation of Overpressure Protection Line Was Noted. Caused by Inadequate Procedural Guidance.Appropriate Operations Dept Procedures Have Been revised.W/980813 Ltr ML18106A6931998-06-29029 June 1998 LER 98-003-00:on 980122,inappropriate Plugging of Tubes R9C60 & R10C60 in Salem Unit 2 Sg,Was Performed.Caused by Failure of Qualification,Verification & Validation Process. Tubes Reviewed to Verify No Others Inappropriately Plugged ML18106A6471998-06-0404 June 1998 LER 98-011-00:on 980505,improper Isolation of Single Cell Battery Charger from 125 Vdc Battery Was Noted.Caused by Inadequate 10CFR50.59 Applicability Review.Placed Procedure SC.MD-CM.ZZ-0024(Q) on Administrative hold.W/980604 Ltr ML18106A6421998-06-0101 June 1998 LER 98-010-00:on 931019,reactor Pressure Vessel Insp Plugs Were Out of Configuration,Was Noted.Caused by Personnel Error.Proper Configuration Was Restored Shortly After Discovery Prior to Entering Mode 2.W/980601 Ltr ML18106A6431998-05-29029 May 1998 LER 98-006-01:on 980227,determined Incorrect Scaling Error of First Stage Pressure Transmitter Existed.Caused by Human Error.Revised Setpoint Calculation SC-MS002-01 & Revised Associated Instrument Calibr Database info.W/980529 Ltr ML18106A6141998-05-18018 May 1998 LER 98-008-00:on 970814,failure to Test 21 & 22 AF 40 Valves in Closed Direction as Required by TS 4.0.5 Was Noted.Caused by Inadequate Design Mod Process.Motor Driven 21/22 AF 40 Valves Were Tested IAW Revised procedure.W/980518 Ltr ML18106A5901998-05-0101 May 1998 LER 98-009-00:on 980405,epoxy Missing from Terminals of H Analyzer Was Noted.Caused by Inadequate Development of Procedure.H Analyzers Were Repaired & Review of Other Safety Related Equipment in Containment Was performed.W/980501 Ltr ML18106A5611998-04-20020 April 1998 LER 98-008-00:on 980323,inadequate Testing of Salem Unit 1 Containment Air Locks Resulted in Entering TS 3.0.3.Caused by less-than-adequate Work Practices During Replacement of Equalizing Valve.Salem Unit 2 Airlocks Were Inspected ML18106A6061998-04-0101 April 1998 Corrected LER 98-004-00:on 980302,failure to Comply W/Tss 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Have Been Taken to Correctly Document Safety Factors.Corrects Prior Similar Occurrences ML18106A4451998-04-0101 April 1998 LER 98-004-00:on 980302,failure to Perform TS 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Were Taken to Correctly Document Safety factors.W/980401 Ltr ML18106A4351998-03-30030 March 1998 LER 98-006-00:on 980227,incorrect Scaling of First Stage Turbine Impulse Pressure Transmitters Noted.Cause Indeterminate.Implemented Procedure Changes & re-scaled Affected Turbine Impulse Pressure transmitters.W/980330 Ltr ML18106A3961998-03-20020 March 1998 LER 98-005-00:on 980219,inoperability of Twelve EDG Fuel Oil Transfer Pump (FOTP) Noted.Caused by Installation of Incorrect Control Switch.Installed Correct off-auto-manual Switch & Verified Operability of Twelve FOTP.W/980320 Ltr ML18106A5781998-03-20020 March 1998 Corrected LER 98-005-00:on 980219,inoperability of 12 Fuel Oil Transfer Pump (Fotp),Noted.Caused by Installation of Incorrect Control Switch.Field Insp Performed to Verify Configuration of Switches for 11,21 & 22 FOTPs ML18106A4021998-03-20020 March 1998 LER 98-007-00:on 980218,failure to Establish Containment Integrity (Closure) Prior to Fuel Movement Was Noted.Caused by Failure to Identify & Include Condensate Pot Vent in Appropriate Valve Lineup.Valves identified.W/980320 Ltr ML18106A4031998-03-20020 March 1998 LER 98-006-00:on 980221,ESF Actuation of 11 & 12 Auxiliary Feedwater Pumps Occurred.Caused by Human Error.Operators Promptly Established Feedwater to All SG & Restored Proper Water levels.W/980320 Ltr 1999-08-26
[Table view] Category:RO)
MONTHYEARML18107A5031999-08-26026 August 1999 LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr ML18107A4691999-07-28028 July 1999 LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr ML18107A4441999-07-0606 July 1999 LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr ML18107A4211999-07-0202 July 1999 LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr ML18107A4321999-07-0101 July 1999 LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr ML18107A4331999-07-0101 July 1999 LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr ML18107A3951999-06-17017 June 1999 LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr ML18107A3661999-06-0909 June 1999 LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr ML18107A3551999-06-0202 June 1999 LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr ML18107A3541999-06-0101 June 1999 LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr ML18107A2931999-05-12012 May 1999 LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr ML18107A2781999-05-10010 May 1999 LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr ML18107A2791999-05-0404 May 1999 LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr ML18107A2741999-05-0303 May 1999 LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr ML18107A2351999-04-23023 April 1999 LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr ML18106B1471999-03-29029 March 1999 LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr ML18106B0701999-02-16016 February 1999 LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr ML18106B0491999-01-28028 January 1999 LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr ML18106B0401999-01-18018 January 1999 LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr ML18106B0081998-12-24024 December 1998 LER 97-001-01:on 970215,failure to Perform TS Surveillance of Component Cooling Water Sys Check Valves Occurred.Caused by Inadequate Communication Between EOP Group & IST Reviewers.Procedure Revised.With 981224 Ltr ML18106B0021998-12-17017 December 1998 LER 98-015-01:on 980924,improper Installation of Test Equipment to RPS Occurred.Caused by Inadequate 10CFR50.59 Applicability Reviews During Past Revs.Revised Procedures. with 981217 Ltr ML18106A9551998-11-0303 November 1998 LER 96-013-01:on 960711,concluded That Current Gain & Bias Settings Had Rendered Overtemperature Delta Temp Protection Channels Inoperable.Caused by Scaling Error.Licensee Will Revise Scaling Calculations.With 981105 Ltr ML18106A9451998-10-30030 October 1998 LER 97-004-01:on 970408,failure to Comply with TS Action Statement,Dg Start & Inadequate Surveillance Testing,Was Noted.Caused by Inadequate Tracking of Inoperable Equipment. Discussed Event & Lessons Learned.With 981022 Ltr ML18106A9491998-10-22022 October 1998 LER 98-015-00:on 980924,identified Improper Installation of Test Equipment to Rps.Cause Indeterminate.Procedures for Installation of Test Equipment for Collection of State Point Data Were Placed on Administrative Hold.With 981022 Ltr ML18106A9301998-10-21021 October 1998 LER 98-014-00:on 980725,noted Improper Calibr of Liquid Radwaste Effluent Line Radiation Monitor.Caused by Inattention to Detail by Maint Personnel.Channel Calibr Was Successfully Performed on 1R18 on 980821.With 981019 Ltr ML18106A9071998-10-0101 October 1998 LER 98-014-00:on 980918,discovered That Fire Barrier Matl for HVAC Ducts Does Not Meet Required Level of Fire Resistance.Cause Indeterminate.Established Appropriate Compensatory Actions for Fire Barriers.With 981001 Ltr ML18106A8951998-09-28028 September 1998 LER 98-012-01:on 980725,noted That Afs Was Operated with Less than Required Number of Operable AFW Pumps.Caused by Improper Procedure Implementation.Runout Protection Pressure Device for 22 AFW Pumps Was Returned to Svc.With 980928 Ltr ML18106A8821998-09-21021 September 1998 LER 98-013-00:on 980820,noted Surveillance of Containment Penetration Overcurrent Protection Devices Missed.Caused by Human Error.Satisfactorily Tested Apprpriate Breakers & Disciplined Involved Personnel.With 980921 Ltr ML18106A8791998-09-16016 September 1998 LER 96-006-01:on 960717,determined That non-radioactive Liquid Basin Radwaste Monitor Inoperable During Low Head Conditions.Caused by Inadequate Design Change Package.Design Change 1EC3663-01 Has Been Installed.With 980916 Ltr ML18106A8801998-09-0808 September 1998 LER 98-013-00:on 980806,operation with TS Required Equipment OOS Was Noted.Caused by Human Error.Reviewed Processes & Practices Re Safety Sys Status Control,Procedure Rev & Extra Training.With 980908 Ltr ML18106A8531998-08-27027 August 1998 LER 98-007-00:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Cause of Event Has Not Yet Been Determined.Assembled Root Cause Team & Replaced Affected tubing.W/980827 Ltr ML18106A8521998-08-27027 August 1998 LER 98-011-00:on 980803,ESFA During a 4KV Automatic Transfer Test Was Noted.Caused by Premature Release of Control Console Pushbutton Due to Inadequate Procedural Step.Revised procedure.W/980827 Ltr ML18106A8421998-08-24024 August 1998 LER 98-012-00:on 980725,discovered That Plant Had Operated in Modes 1 & 2 w/twenty-two AFW Pumps Inoperable.Caused by Failure to Restore Pump Runout Protection Pressure Device to Svc.Returned Subject Device to svc.W/980824 Ltr ML18106A8431998-08-24024 August 1998 LER 98-009-00:on 980810,failure to Post Continuous Firewatch as Required by Fire Protection Plan Noted.Caused by Failure to Recognize Concurrent Conditions.Continuous Firewatch Was Posted Immediately & Repaired Smoke detectors.W/980824 Ltr ML18106A8141998-08-13013 August 1998 LER 98-010-00:on 980714,determined That Leakage from Boron Injection Tank Exceeded Max Allowable ECCS Leakage from Sources Outside Containment.Caused by Leaking 2SJ404 Manual Sample valve.2SJ404 Valve repaired.W/980813 Ltr ML18106A8201998-08-13013 August 1998 LER 98-012-00:on 980715,potential to Exceed Rating of Piping Due to Isolation of Overpressure Protection Line Was Noted. Caused by Inadequate Procedural Guidance.Appropriate Operations Dept Procedures Have Been revised.W/980813 Ltr ML18106A6931998-06-29029 June 1998 LER 98-003-00:on 980122,inappropriate Plugging of Tubes R9C60 & R10C60 in Salem Unit 2 Sg,Was Performed.Caused by Failure of Qualification,Verification & Validation Process. Tubes Reviewed to Verify No Others Inappropriately Plugged ML18106A6471998-06-0404 June 1998 LER 98-011-00:on 980505,improper Isolation of Single Cell Battery Charger from 125 Vdc Battery Was Noted.Caused by Inadequate 10CFR50.59 Applicability Review.Placed Procedure SC.MD-CM.ZZ-0024(Q) on Administrative hold.W/980604 Ltr ML18106A6421998-06-0101 June 1998 LER 98-010-00:on 931019,reactor Pressure Vessel Insp Plugs Were Out of Configuration,Was Noted.Caused by Personnel Error.Proper Configuration Was Restored Shortly After Discovery Prior to Entering Mode 2.W/980601 Ltr ML18106A6431998-05-29029 May 1998 LER 98-006-01:on 980227,determined Incorrect Scaling Error of First Stage Pressure Transmitter Existed.Caused by Human Error.Revised Setpoint Calculation SC-MS002-01 & Revised Associated Instrument Calibr Database info.W/980529 Ltr ML18106A6141998-05-18018 May 1998 LER 98-008-00:on 970814,failure to Test 21 & 22 AF 40 Valves in Closed Direction as Required by TS 4.0.5 Was Noted.Caused by Inadequate Design Mod Process.Motor Driven 21/22 AF 40 Valves Were Tested IAW Revised procedure.W/980518 Ltr ML18106A5901998-05-0101 May 1998 LER 98-009-00:on 980405,epoxy Missing from Terminals of H Analyzer Was Noted.Caused by Inadequate Development of Procedure.H Analyzers Were Repaired & Review of Other Safety Related Equipment in Containment Was performed.W/980501 Ltr ML18106A5611998-04-20020 April 1998 LER 98-008-00:on 980323,inadequate Testing of Salem Unit 1 Containment Air Locks Resulted in Entering TS 3.0.3.Caused by less-than-adequate Work Practices During Replacement of Equalizing Valve.Salem Unit 2 Airlocks Were Inspected ML18106A6061998-04-0101 April 1998 Corrected LER 98-004-00:on 980302,failure to Comply W/Tss 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Have Been Taken to Correctly Document Safety Factors.Corrects Prior Similar Occurrences ML18106A4451998-04-0101 April 1998 LER 98-004-00:on 980302,failure to Perform TS 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Were Taken to Correctly Document Safety factors.W/980401 Ltr ML18106A4351998-03-30030 March 1998 LER 98-006-00:on 980227,incorrect Scaling of First Stage Turbine Impulse Pressure Transmitters Noted.Cause Indeterminate.Implemented Procedure Changes & re-scaled Affected Turbine Impulse Pressure transmitters.W/980330 Ltr ML18106A3961998-03-20020 March 1998 LER 98-005-00:on 980219,inoperability of Twelve EDG Fuel Oil Transfer Pump (FOTP) Noted.Caused by Installation of Incorrect Control Switch.Installed Correct off-auto-manual Switch & Verified Operability of Twelve FOTP.W/980320 Ltr ML18106A5781998-03-20020 March 1998 Corrected LER 98-005-00:on 980219,inoperability of 12 Fuel Oil Transfer Pump (Fotp),Noted.Caused by Installation of Incorrect Control Switch.Field Insp Performed to Verify Configuration of Switches for 11,21 & 22 FOTPs ML18106A4021998-03-20020 March 1998 LER 98-007-00:on 980218,failure to Establish Containment Integrity (Closure) Prior to Fuel Movement Was Noted.Caused by Failure to Identify & Include Condensate Pot Vent in Appropriate Valve Lineup.Valves identified.W/980320 Ltr ML18106A4031998-03-20020 March 1998 LER 98-006-00:on 980221,ESF Actuation of 11 & 12 Auxiliary Feedwater Pumps Occurred.Caused by Human Error.Operators Promptly Established Feedwater to All SG & Restored Proper Water levels.W/980320 Ltr 1999-08-26
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20217A9931999-09-30030 September 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data ML18107A5581999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Salem,Unit 2.With 991014 Ltr ML18107A5571999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Salem,Unit 1.With 991014 Ltr ML18107A5301999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Salem,Unit 2.With 990913 Ltr ML18107A5311999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Salem,Unit 1.With 990913 ML18107A5031999-08-26026 August 1999 LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr ML18107A5201999-08-12012 August 1999 Rev 0 to Sgs Unit 2 ISI RFO Exam Results (S2RFO#9) Second Interval,Second Period, First Outage (96RF). ML18107A4811999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Salem,Unit 1.With 990813 Ltr ML18107A4821999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Salem,Unit 2.With 990813 Ltr ML18107A4691999-07-28028 July 1999 LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr ML18107A4441999-07-0606 July 1999 LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr ML18107A4211999-07-0202 July 1999 LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr ML18107A4331999-07-0101 July 1999 LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr ML18107A4321999-07-0101 July 1999 LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr ML18107A5211999-07-0101 July 1999 Rev 0 to Sgs Unit 2 ISI RFO Exam Results (S2RFO#10) Second Interval,Second Period,Second Outage (99RF). ML18107A4351999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Salem,Unit 1.With 990713 Ltr ML18107A4341999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Salem,Unit 2.With 990713 Ltr ML20196H8621999-06-30030 June 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept ML18107A3951999-06-17017 June 1999 LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr ML18107A3661999-06-0909 June 1999 LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr ML18107A3551999-06-0202 June 1999 LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr ML18107A3441999-06-0101 June 1999 Interim Part 21 Rept Re Premature Over Voltage Protection Actuation in Circuit Specific Application in Dc Power Supply.Testing & Evaluation Activities Will Be Completed on 990716 ML18107A3541999-06-0101 June 1999 LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr ML18107A3681999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Salem Generating Station,Unit 1.With 990611 Ltr ML18107A3721999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Salem Generating Station,Unit 2.With 990611 Ltr ML18107A2931999-05-12012 May 1999 LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr ML18107A2781999-05-10010 May 1999 LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr ML18107A2791999-05-0404 May 1999 LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr ML18107A2741999-05-0303 May 1999 LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr ML18107A3711999-04-30030 April 1999 Corrected Monthly Operating Rept for Apr 1999 for Salem Generating Station,Unit 1 ML18107A3151999-04-30030 April 1999 Submittal-Only Screening Review of Salem Generating Station Individual Plant Exam for External Events (Seismic Portion), Rev 1 ML18107A2991999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Salem Unit 1.With 990514 Ltr ML18107A2971999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Salem Unit 2.With 990514 Ltr ML18107A2351999-04-23023 April 1999 LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr ML18107A2881999-04-0707 April 1999 Rev 0 to NFS-0174, COLR for Salem Unit 2 Cycle 11. ML18107A1821999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Salem,Unit 1.With 990414 Ltr ML18107A1831999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Salem,Unit 2.With 990414 Ltr ML18106B1471999-03-29029 March 1999 LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr ML18106B1021999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Salem Unit 2.With 990315 Ltr ML18106B1011999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Salem Unit 1.With 990315 Ltr ML18106B0931999-02-25025 February 1999 Part 21 Rept Re Possible Defect in Swagelok Pipe Fitting Tee,Part Number SS-6-T.Caused by Crack Due to Improper Location of Heated Bar.Only One Part Out of 7396 Pieces in Forging Lot Was Found to Be Cracked.Affected Util,Notified ML18106B0701999-02-16016 February 1999 LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr ML18106B0551999-02-0101 February 1999 Part 21 Rept Re Possible Matl Defect in Swagelok Pipe Fitting Tee,Part Number SS-6-T.Defect Is Crack in Center of Forging.Analysis of Part Is Continuing & Further Details Will Be Provided IAW Ncr Timetables.Drawing of Part,Encl ML18106B0561999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Salem Generating Station,Unit 2.With 990212 Ltr ML18106B0571999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Salem Generating Station,Unit 1.With 990212 Ltr ML20205P1671999-01-31031 January 1999 a POST-PLUME Phase, Federal Participation Exercise ML18106B0441999-01-29029 January 1999 Part 21 Rept Re Possible Defect in Swagelok Pipe Fitting Tee Part Number SS-6-T.Caused by Crack in Center of Forging. Continuing Analysis of Part & Will Provide Details in Acoordance with NRC Timetables ML18106B0491999-01-28028 January 1999 LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr ML18106B0401999-01-18018 January 1999 LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr ML18106B0251998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Salem Unit 2.With 990115 Ltr 1999-09-30
[Table view] |
Text
* NRCFORM 368 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 (4-95) EXPIRES IM/30198 EVENT REPORT (LER) ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS MANDATORY INFORMATION COLLECTION REQUEST: 50.0 HRS. REPORTED LESSONS LEARNED ARE INCORPORATED INTO THE LICENSING PROCESS ANO FED BACK TO INDUSTRY.
FORWARD (See reverse for required number of COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION ANO RECORDS MANAGEMENT BRANCH g-e F33), U.S. NUCLEAR digits/characters for each block) REGULATORY COMMISSION, WASHINGT N, DC 20656-0001, ANO TO THE PAPERWORK REDUCTION PROJECT (316CM>104), OFACE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503. FACILITY NAME (1) DOCKET NUMBER (2) PAGE (3) SALEM -Unit 1 05000272 1 OF 10 TITLE (4) Technical Specification Violations:
Differential Pressure of the Fuel Handling Building Ventilation System EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8) YEAR I 'REVISION FACILITY NAME DOCKET NUMBER MONTH DAY YEAR SEQUENTIAL MONTH DAY YEAR NUMBER NUMBER Salem Unit 2 05000311 09 11 95 95 024 00 10 11 95 FACILITY NAME DOCKET NUMBER ----OPERATING THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check one or more) (11) MODE(9) A 20.2201(b) 20.2203(a)(2)(v) x 50. 73(a)(2)(i)(B)
- 50. 73(a)(2)(viii)
POWER 20.2203(a)(1) 20.2203(a)(3)(i)
- 50. 73(a)(2)(ii)
- 50. 73(a)(2)(x) iii 20.2203(a)(2)(i) 20.2203(a)(3)(ii)
- 50. 73(a)(2)(iii) 73.71 20.2203(a)(2)(ii) 20.2203(a)(4)
- 50. 73(a)(2)(iv)
OTHER 20.2203(a)(2)(iii) 50.36(c)(1)
- 50. 73(a)(2)(v)
Abstract below . or In C Form 366A 20.2203(a)(2)(iv) 50.36(c)(2)
- 50. 73(a)(2)(vii)
LICENSEE CONTACT FOR THIS LER (12) NAME TELEPHONE NUMBER (Include Ame Code) Zarechnak, A. (Mgr., Mechanical Engineering)
(609) 339-1755 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13) CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE II CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TONPRDS TONPRDS . VG N I SUPPLEMENTAL REPORT EXPECTED (14) EXPECTED MONTH DAY YEAR IYES x1NO SUBMISSION (If yea, complete EXPECTED SUBMISSION DATE). ..lATE (15) ABSTRACT (Limit to 1400 apacH, i.e., approximately 15 1ingle-11peced typewritten lines) (16) On 8/23/95, it was identified that the low differential pressure (dp) alarm for the Unit 2 Fuel Handling Building(IBB) was wired incorrectly since 1991. This error has been subsequently corrected.
On 9/8/95, it was identified that Technical Specification(TS)
Action Statements were recently entered due to intermittent alann conditions.
On 9/11/95, it was determined that the E1IB dp Surveillance Testing (ST) did not ensure compliance with TS requirements in that it did not ensure the required dp was maintained during normal system operation.
In addition, investigation revealed that a design issue remained unresolved since 1990 concerning a disparity between the Fuel Handling Ventilation (FHV) controller setting and the TS dp requirement.
Also, routine changes to the FHV system configuration during normal operation were found to have degraded the continuous compliance with the TS limit over the life of the facility.
This condition also applies to Salem Unit 1. This event is reportable per 10CFR50.73(a)
(2) (i) (B) "Technical Specification Violation".
Corrective actions include assuring that design basis open items affecting operability of the FHV system are properly prioritized and resolved, revising affected ST proced1_1res, and correcting dp alarm and controller setpoints prior to restart. 9510160164 950911 NRC FORM 388 (4-95) PDR ADOCK 05000272 S PDR
- NRC FORll 366A (4-95) U.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER 6) Salem Unit 1 05000272 TEXT (If more space i* required, use additional copies of NRC Form 366A) (17) PLANT .AND SYSTEM IDENTIFICATION Westinghouse
-Pressurized Water Reactor YEAR I SEQUENTIAL NUMBER REVISION NUMBER 95 -024 -00 Fuel Handling Building Ventilation System -EIIS Identifier
{VG} IDENTIFICATION OF OCCURRENCE Discovery Date: Report Date September 11, 1995 October 11, 1995 CONDITIONS PRIOR TO OCCURRENCE Operational Mode: Reactor Power: Defueled (Salem 1), 5 (Salem 2) 000% Both units DESCRIPTION OF OCCURRENCE PAGE (3) 2 OF 10 On 8/23/95, while Unit 2 was shutdown and in Mode 5, a problem with the low differential pressure (dp) alarm for the Fuel Handling Building(FHB)
Ventilation system was identified.
This condition was identified when the Fuel Handling Building-Ventilation (FHV) fans were removed from se.rvice for scheduled maintenance and the appropriate Technical Specification(TS)
Action Statement(AS) was entered. Upon noticing that an alarm condition was not present, Operations directed I&C to troubleshoot the condition.
Investigation revealed that the alarm switch had been miswired.
The wiring was corrected and due to continuous alarm conditions, the alarm was temporarily set to actuate on increasing pressure of 0.00 inch water gauge ("wg). The Unit 2 dp alarm setpoint was historically maintained at -.1" wg except for a briefperiod beginning 8/26/95 when the setpoint was changed to 0.0" wg. In the following weeks, several dp alarm conditions were received in the control room and Operator actions were required.
These actions included, entering TSASs and investigating the cause of the alarm conditions.
On one occasion, Operations personnel found contractor personnel manipulating a non-safety related damper. Investigation further found that unauthorized changes to the differential pressure controller setpoint also occurred.
The incorrect damper positions, and controller setpoints were corrected following each occurrence.
These uncontrolled changes to the FHV system configuration degraded the ability to comply with the TS dp limits over the spent fuel pool area. On September 11, 1995 surveillance testing was conducted on Salem Unit 2 to satisfy the TS 4.9.12.d.3 requirements for maintaining the fuel handling building (FHB) differential pressure (dp) at -0.125" wg relative to the outside atmosphere.
This test was performed while the FHV controller setpoint was increased to -0.13" wg from the normal -0.1" wg setting. As a result, the test NRC FORM 366A (4-95)
- NRC FORll 366A (4-95) U.S. NUCLEAR REGULATORY COllMISSION FACILITY NAME (1) SALEM -Unit 1 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER (2) LER NUMBER (6) YEAR I SEQUENTIAL I REVISION NUMBER 05000272 95 -024 -00 TEXT (If more apace ia required, uae additional copies of NRC Form 366A) (17) Description of Occurrence (Cont'd) PAGE (3) 3 OF 10 conditions were not representative of the normal system operating conditions and failed to meet the TS surveillance requirements for the FHV system. It was later determined that the controller setpoint had also been increased during previous surveillance tests for both Salem Units 1 and 2. These control setpoint changes, as well as system maintenance changes, were made prior to the testing to ensure that the dp measured over the spent fuel pool satisfied the TS requirements.
Following the test, the controller setpoint would be returned to -.1" wg. As a result of the conditions and observations below, the required -1/8" wg dp above the spent fuel pool area cannot be assured to have been maintained over the life of the operating units. Therefore numerous TS action statement entries were potentially missed. These conditions and observations include:
- inadequate surveillance testing,
- miswired alarm condition for a four year period,
- inadequate post maintenance testing,
- lack of documented basis for the controller and alarm settings,
- alarm conditions subsequent to the wiring correction when setpoint was at 0.0" wg, and a System Engineering Assessment Transmittal (SEAT) provided dir"ection to set the alarm to 0. 0" wg in 1991, and
- uncontrolled manipulation of non-safety inlet dampers and controller setpoints.
Salem has historically used a differential pressure controller setpoint of -0.1" wg and an alarm setpoint of -0.1" wg for both units. Since 10/16/91, the Unit 1 dp alarm setpoint was changed to 0.0" wg. The Unit 2 dp alarm setpoint was changed to 0.0" wg since 8/26/95. Currently, the controller setpoint for both units is maintained at 0.2" wg. The controller setting was consistent with UFSAR section 9.4.3.2.2.
This controller setting appears to conflict with the TS requirement of -0.125" wg; however, the location of the controller alarms and sensors influence their setpoints and, under the current configuration, are supposed to be different than the TS dp requirement applicable directly over the spent fuel pool area. The spent fuel pool area, referred to in the TS, is defined in the UFSAR as a ten foot height above the pool. However, no engineering documentation which establishes the basis for the FHV differential pressure controller and alarm setpoints could be located. In addition, design modifications to the FHB ventilation system (e.g., installation of backdraft installation of vane stops, etc) could have rendered previously determined controller settings and alarm setpoints to be inadequate.
NRC FORM 366A (4-95)
NRC FORM 366A (4-95) FACILITY NAME (1) SALEM -Unit 1
- U.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER (2) LER NUMBER 6) YEAR I SEQUENTIAL NUMBER REVISION NJMBER PAGE (3) 05000272 95 -024 -00 4 OF 10 TEXT (If more apace ia required, uae additional copiea of NRC Form 366A) (17) Description of Occurrence (Cont'd) The status of the FHV system is inoperable on both Salem units. All fuel movements and FHB crane operations have been suspended pending completion of the spent fuel pool dp surveillance test . .Analysis of Occurrence The FHV system is designed to operate continuously during normal and emergency plant operations to maintain the atmosphere of the fuel handling building separate from the environment and the other Salem Station buildings.
In an accident condition, the exhaust from the E1IV is HEPA/charcoal filtered to control the spread of any fuel handling related contaminants.
A negative pressure is maintained in the building to prevent unfiltered out-leakage from the building.
These safety related ventilation functions are monitored to ensure there is no release of contaminants to the atmosphere.
The monitoring of the FHB dp is provided on a continuous basis from the control room through the BUILDING AIR D/P LO alarm and periodic TS surveillance testing. The differential pressure historically used for the low dp alarm setpoint (-0.1" wg) and that required by the testing (-0 .125" wg) are different.
Further, the differential pressure controller setpoint (-0.1" wg) was less negative than that required by the Technical Specification.
On September 16, 1995, a special test was performed to demonstrate the relationship between the TS requirement for dp above the spent fuel pool and the differential pressure measured at the controller and alarm location.
The special test indicates that a dp of 0.025" wg (when extrapolated) may exist between the pool and the controller with a controller setpoint of -0.1" wg. This indicates that the controller setpoint of -0.1 in. wg could have had an adequate basis (although undocumented) under the original FHB design configuration.
This further provided evidence that actual dp above the spent fuel area is more negative than the alarm setting thus indicating less potential for unmonitored and unfiltered airborne contaminant releases.
These test results are currently being evaluated by engineering as part of the resolution of the open Discrepancy Evaluation Form (DEF) . Investigation further revealed that compliance with the TS was previously provided by temporarily increasing the differential pressure controller setpoint during TS surveillance testing. This step is not includea in the testing procedure but was a normal testing practice.
At that time, based on the verbal direction provided from Engineering, it was believed that the purpose of the surveillance test was to demonstrate the capability of FHV system to achieve -.125" wg pressure differential over the spent fuel pool. The design basis of the system regarding this issue was not documented.
However, the compliance of the FHV system with the Technical Specification requirement for differential NRC FORM 366A (4-95)
- NRC FORM 366A (4-116) U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME (1) SALEM -Unit 1 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER (2) LER NUMBER (6) YEAR I SEQUENTIAL I REVISION NUMBER 05000272 95 -024 -00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17) Analysis of Occurrence (Cont'd) PAGE (3) 5 OF 10 pressure is required on a continuous basis and was therefore unproven by the surveillance test. Further, the Technical Specification testing was performed using an undocumented process (i.e., following steps prescribed by previous practice but not identified in the procedure) . Also, it was noted that the ST procedure did not require recording of the "as-found" and "as-left" condition.
It was also found that these differences were not reported to operations as required by the "TS Surveillance Program" which states, in part; "Notify the Job Supervisor and the SNSS/NSS as soon as possible whenever As-Found conditions do not meet Technical Specification allowable values". These concerns with the operation of the FHV system apply to both Salem units. The specific relationship of the Technical Specifications to the FHV system design basis and operability has been a concern at Salem since 1990. The problem was previously identified for engineering resolution as part of the Configuration Basis Document (CBD) (Design Reconstitution) effort begun in 1988 and documented in a DEF in 1990. However, the basis for the resolution priority assigned to these issues did not consider HVAC systems a priority in terms of safety significance.
Sensitivity by engineering to the importance of HVAC systems remained inadequate as eveidenced by the fact that this issue remains unresolved to date. Furthermore, it was by engineering-verbal direction that the interpretation was adopted wherein the purpose of the surveillance test was thought to be that the system is capable of achieving the required TS value. In addition, a SEAT was generated in 1991 which provided the basis for the 0.0" wg setpoint for the alarm. The Unit 1 dp alarm setpoint was changed on 10/16/91 to 0.0" wg. The Unit 2 alarm was changed on 8/26/95. Failure to understand the system design basis also resulted in the unauthorized manipulation of the FHV systems controls.
The design basis for the differential pressure alarm and controller setpoints was not documented.
Therefore, the system was manipulated on the supply side, non-safety related portion of the system, to improve the comfort of the personnel working in the FHB without understanding the impact on the safety related function of the ventilation system. Changes from the specified system line-up were found to be the cause of the fuel handling building differential pressure alarms on several occasions.
The local differential pressure controls were not designed or labeled to protect from this type of manipulation.
In addition, the significance of changing the non-safety alarm setpoint to 0.0" wg following the rewiring correction was not understood.
The operator response to the alarm conditions was also investigated; however the review was incomplete and inconclusive.
The investigation revealed that operators properly identified the absence of an alarm condition in mid-August
'95 which led to discovery of the wiring error. In addition, operators NRC FORM 366A (4-95)
- NRC FORll 366A (4-115) U.S. NUCLEAR REGULATORY COlllllSSION LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) YEAR I SEQUENTIAL I REVISION NUMBER NUMBER SALEM -Unit 1 05000272 95 -024 -00 TEXT (If more apace ia required, uae additional copies of NRC Form 366A) (17) Analysis of Occurrence (Cont'd) PAGE(3) 6 OF 10 responded to alarm conditions as evidenced by identifying contractor personnel manipulating non-safety related dampers. This review also revealed that the TS AS was not consistently entered immediately upon alann indication.
Interviews with three operators indicated that the Action Statement was not entered if the alann cleared within a minute. The alarm response procedure was also reviewed.
The procedure does not specifically require the operator to enter into an Action Statement; rather, the alann response procedure states: "3.1 3.2 STOP any Fuel Handling in progress.
Notify SNSS/NSS to refer to Technical Specifications".
Operator response to the FHB dp alarm, operator involvement in approval of the work order which allowed manipulation of the non-safety damper, and adequacy of the alann response procedure will be further investigated.
Prior Similar Occurrences Recent other reportable issues involving the Salem Station ventilation (HVAC) include 272/95-06, 272/95-08, 272/95-17, 272/95-19, and 272/95-22.
These issues suggest that a heightened awareness and understanding of licensing and design basis requirements associated<with HVAC systems is required.
In addition, the System Readiness Reviews have identified deficiencies in the plant ventilation systems. Action has been initiated to evaluate the aggregate impact of these deficiencies on the plant. A cumulative impact evaluation will be perfonned to identify any additional corrective actions required other than the corrective actions listed in the individual LERs. Safety Significance Actual The negative differential pressure requirement for the operation of the FHV system has a direct impact on the potential for unmonitored off-site release. The deficiency in the Technical Specification implementation and system maintenance could have resulted in periods of operation when unmonitored leakage from the fuel handling building was possible.
The safety significance of this degraded condition is low since no fuel handling or crane operation accidents occurred to cause a significant release. The special test conducted provided further evidence that actual dp above the spent fuel area is more negative than at the location of the alarm and controller thus indicating less potential for unmonitored and unfiltered airborne contaminant releases.
NRC FORM 366A (4-95)
- NRC FORM 388A (4-116) U.S.
REGULATORY COlllllSSION LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) YEAR I SEQUENTIAL I REVISION NUMBER l\ll-"EER SALEM -Unit 1 05000272 95 -024 -00 TEXT (If more apace ia required, use additional copies of NRC Form 366A) (17) Safety Significance (Cont'd) Potential PAGE(3) 7 OF 10 A review was performed by Nuclear Fuels to determine the potential significance of an unmitigated release (i.e., inoperable F1IV system) following a fuel handling accident.
This accident assumes a release of the gaseous fission products contained in the fuel rod gap of all 264 fuel rods in a single assembly.
Fission product inventories were estimated using the ORIGEN-2 code. It further assumed a dropped fuel assembly burned to 65,000 MWD/MTU and, prior to the outage, the reactor had been operating at 3600MWth (105.5% of rated power) . The iodine and xenon inventories were assumed to be conservatively proportional to the radial power peaking factor, which was in turn, conservatively set to l.70(current TS limit per 3.2.3 is 1.55). Technical Specification 3/9.3 requires that the reactor remain subcritical for 168 hours0.00194 days <br />0.0467 hours <br />2.777778e-4 weeks <br />6.3924e-5 months <br /> prior to the movement of irradiated fuel. These inputs along with an assumed filter decontamination factor of 1.0 (i.e., no filtration of airborne source terms) yielded offsite doses within the limits of 10 CFR Part 100. It should be noted that an unfiltered fuel handling accident release was assumed as part of the calculation for GDC-19 compliance.
For both the actual and potential cases above, the actuation of the alarm caused by the existence of a high radiation signal from the local radiation monitor would have alerted the operators and resulted in operator cognizance and requisite mitigative actions. cause of Occurrence A significant cause of this issue was determined to be inadequate design basis information; several contributing causes are also discussed below. The ventilation system TS requirement for maintaining a negative dp in the F1IB was not well understood as evidenced by the TS interpretation that the surveillance only has to demonstrate that the system is capable of achieving the required value. In addition, the lack of sensitivity to the safety significance of the ventilation system was evidenced by its low priority for resolution.
Specific inconsistencies exist between the design basis information reflected in the E1IV system configuration basis document (CBD), UFSAR, and the TS. The incomplete and conflicting design basis information resulted in:
- inappropriate selection of the E1IV alarm and control set points,
- inadequate understanding of the intent of the Technical Specification requirements,
- inadequate surveillance procedure instructions and conduct of testing,
- incorrect manipulation of portions of the F1IV system,
- inadequate requirements for post maintenance testing and periodic maintenance of non-safety HVAC components which affect compliance with HVAC TS requirements, and NRC FORM 366A (4-95)
- NRC FORll 366A (4-85) U.S. NUCLEAR REGULATORY COlllllSSION LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) YEAR I SEQUENTIAL I REVISION NUMBER llAJMBER SALEM -Unit 1 05000272 95 -024 -00 TEXT (If more space i* required, use additional copies of NRC Form 366A) (17) Cause of Occurrence (Cont'd) PAGE (3) 8 OF 10
- inadequate understanding of the effect of HVAC non-safety related components on HVAC TS compliance.
These concerns with the design basis information also extend, at least in part, to other Salem HVAC systems. Previously identified design basis inconsistencies and documentation inadequacies require resolution on these systems especially as they relate to the resolution of open DEFs. Inadequate control over the local operation and adjustment of the FHV system components also affected the Technical Specification compliance.
A standing work order for the FHV System allowed for unspecified changes to the system without specific review. The lack of cognizance (system operating and testing requirements) by testing, maintenance, work control, operations and engineering personnel, as well as the incomplete surveillance testing procedures, was indicative that the level of understanding was not commensurate with the safety significance of the FHV system. The system design, the station operations procedures and work control practices did not ensure the FHV system configuration was protected from changes impacting the TS. The use of Radiation Protection personnel for the conduct of the HVAC surveillance testing and their respective training was ineffective in ensuring compliance with TS requirements.
It should be noted that the review results to date regarding Operations response to the FHB dp alarm were not considered to be a significant contributor to the FHV problems.
Further review will be performed.
Corrective Actions The corrective actions listed below apply to both Salem units, except as noted otherwise.
Immediate Actions Taken Immediate Actions taken to ensure FHV system operability associated with the FHB dp for both Salem units include:
- changed the FHV dp controller setpoints to be more* negative than the -0.125" wg TS requirement.
- Added local monitoring of the FHV dp controller to the Operator rounds.
- Ensured operability of the FHB dp alarm.
- Verified the TS requirements for air flow and determined that it had no impact on current FHB system operation
- Following the initial immediate actions, a new electronic controller and alarm sensor was installed in Unit 2; similar to that which was previously installed in Unit 1. NRC FORM 366A (4-95)
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- NRC FORM 366A (4-95) U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME (1) SALEM -Unit 1 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER 121 LER NUMBER (6) YEAR I SEQUENTIAL I REVISION NUMBER NUMBER 05000272 95 -024 -00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17) Corrective Actions (Cont'd) Near Term Actions PAGE(3) 9 OF 10
- A surveillance test will be perform.ed using the revised methodology prior to declaring the system operable and prior to the formal revision of the procedure referred to in "Long Term. Corrective Actions".
This testing is expected to be completed by October 23, 1995.
- Direction will be provided to appropriate personnel regarding the impact of manipulating non-safety FHV components on the operability of the FHV system. This direction is expected to be provided prior to declaring the FHV system operable.
- The FHV dp alarm setpoints will be reset to -0.13" wg until such time that the design basis setpoint is determ.ined by Engineering in item 1 below. Long Term Corrective Actions The causes of the concerns will be addressed as follows: 1. Establish the design basis and setpoints for the FHV system pressure controller, differential pressure switch (alarm.), and radiation monitors.
This activity is expected to be completed by December 11, 1995. 2. Disposition all open issues identified in DEFs which affect the operability of the FHV system prior to restart, which is exp0cted during the first and second quarter of 1996 for Units 1 and 2, respectively.
- 3. Identify inconsistencies between the established design, technical specifications and surveillance test procedures prior to restart, which is expected during the first and second quarter of 1996 for Units 1 and 2, respectively.
- 4. The impact of the Technical Specification changes and clarifications developed on the design, testing, and maintenance of the FHV system will be formally communicated to appropriate personnel . This training will be provided to appropriate personnel prior to restart, which is expected during the first and second quarter of 1996 for Units 1 and 2, respectively
- . 5. A condition resolution has been initiated to address the failure to detect the rniswired alarm. 6. Evaluate and identify, where required, the need for controls to prevent unauthorized manipulation of HVAC components (e.g., dampers, vents, controllers, alarms, etc) which can affect TS compliance/operability of a safety related system. NRC FORM 366A (4-95) NRC FORM 366A (4-95)
NRC FORll 366A (4-96) *
- FACILITY NAME (1) SALEM -Unit 1 U.S. NUCLEAR REGULATORY COlllllSSION LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER (2) LER NUMBER (6) YEAR I SEQUENTIAL I REVISION NUMBER PAGE (3) 05000272 95 -024 -00 10 OF 10 TEXT (If more space is required, use additional copies of NRC Form 366A) (17) Long Tenn Corrective Actions (Cont'd) 7. Operator response to the E1IB dp alann condition, involvement in approval of the work order which allowed manipulation of the non-safety damper, and adequacy of the alann response procedure will be further investigated.
- 8. Action has been initiated to evaluate the aggregate impact of the HVAC deficiencies, as discussed in "Prior Similar Occurences".
A cumulative impact evaluation will be perfonned to identify any additional corrective actions required other than those considered in the corrective actions listed in the individual LERs. A supplement to this LER will be provided if the corrective actions taken as a result of this LER determine that additional TS violations were found to have existed. All corrective actions will be taken in accordance with the revised corrective action program. NRC FORM 386A (4-95)