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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML20029E2061994-05-11011 May 1994 LER 93-025-01:on 931205,Loop a MSIVs Exceeded TS Leakage Limit.Caused by Failure of Fastner Locking Devices.Seating Surface of Main Disc in MSIV 1A Machined & Successfully Pass LLRT on 940116.W/940511 Ltr ML17352B2501993-10-0101 October 1993 LER 93-014-00:on 930902,discovered That IRM 11 & APRM Both in Bypassed Condition W/O Half Scram Being Inserted Due to Work Practices.Irm 11 Taken Out of Bypassed Condition & Individual Involved counselled.W/931001 Ltr ML17352B2511993-10-0101 October 1993 LER 93-019-00:on 930903,RHR Pump 1A Inadvertently Started Due to Personnel Error.Pump Immediately Secured & Individual Involved Counselled on Importance of self-check.W/931001 Ltr ML20046A1801993-07-21021 July 1993 LER 92-007-00:on 930624,Toxic Gas Analyzer Inoperable Due to Personnel Error Caused by Lack of Procedural Adherence. Isolated CR Ventilation,Restarted Sample Pump & Restored CR Ventilation Sys to Outside Air suction.W/930721 Ltr ML20045H5781993-07-13013 July 1993 LER 93-013-00:on 930613,internal Electrical Fault within Main Power Transformer Tripped & Caused Reactor Scram & Unexpected Group I Isolation.Caused by Turbine Stop Valve Closure.Transformer replaced.W/930713 Ltr ML20045G7291993-07-0909 July 1993 LER 93-005-00:on 930609,numerous Alarms Received in CR, Including HPCI Turbine Rupture Disc High Pressure Alarm. Caused by Ruptured Disk,Releasing Steam/Water Mixture. Test Will Be Conducted on Rupture disks.W/930709 Ltr ML20045G0951993-07-0202 July 1993 LER 93-011-00:on 930602,HPCI Declared Inoperable in Order to Perform Qcos 2300-13.Caused by MSC Stem & Stem Gear Being Scored & Worn from Age Causing Excessive Friction.C/As Include Disassembling Gearbox Every 10 yrs.W/930702 Ltr ML20045F3321993-06-30030 June 1993 LER 93-012-00:on 930601,U-2 DG Cooling Water Pump Inoperable Due to Inadequate lubrication.U-2 DG Cooling Water Pump replaced.W/930630 Ltr ML20045F3251993-06-28028 June 1993 LER 93-007-01:on 930307,B Loop MSIV Exceeded TS Leakage Limits for Containment Isolation Valves Caused by Damaged Flexitalic Bonnet Gasket.Replaced Bonnet Gasket & Valve Successfully Retested (WR Q061987).W/930622 Ltr ML20044E6171993-05-14014 May 1993 LER 93-006-00:on 930420,Unit 2 Nso Inadvertently Started Unit 1 DG When Attempting to Start Shared (1/2) Dg.Caused by Personnel Error.Unit 1 DG Shut Down & 1/2 DG Started & Loaded successfully.W/930514 Ltr ML20044C9511993-05-0707 May 1993 LER 93-009-00:on 930408,technician Discovered That Estimate of Sample Flow for U2 Reactor Bldg Vent Sampler Flow Rate Monitor Not Calculated.Caused by Personnel Error.Technician counseled.W/930428 Ltr ML20024G6811991-04-19019 April 1991 LER 91-008-00:on 910322,reactor Bldg Ventilation Isolation Occurred.Caused by Lightning Strike.Control Room Vents Reset & Toxic Gas Sample Point a Selected.Addl Trips Associated W/ Lightning Strike Immediately reset.W/910418 Ltr ML20029C1241991-03-0808 March 1991 LER 91-005-01:on 910131,1/2 B Standby Gas Treatment Sys Autostart During RPS B Power Swap Due to an Inadequate Procedure.Nso Reset 1/2 Scram & 1/2 Groups II & III isolations.W/910306 Ltr ML20029B5901991-03-0808 March 1991 LER 91-004-00:on 910211,standby Liquid Control Sys of Unit 1 & 2 Inoperable.Caused by Inadequate Mod Testing.Engineering Dept Evaluating Data & Temporary Procedure 6589 Generated. W/910308 Ltr ML20028H7841991-01-23023 January 1991 LER 90-032-00:on 901224,1/2A Diesel Fire Pump Taken out-of- Svc on 901217 & Not Returned to Svc Before Seven Day Time Allotment Expired.Caused by Mgt Deficiency.Fire Pump Successfully Tested & Returned to svc.W/910123 Ltr ML20028H6831991-01-21021 January 1991 LER 90-034-00:on 901223,high Chlorine Concentration Caused Control Room Ventilation Manual Isolation & ESF Actuation. Caused by Instrument Error Code & Misinterpretation of Analyzer Indication.Flow reduced.W/910121 Ltr ML20028G9141990-09-28028 September 1990 LER 90-018-00:on 900829,plant Outside Design Spec for Electrical Separation Criteria for Two Redundant Safety Sys. Caused by Inadequate Engineering Review During Leads installation.W/900928 Ltr ML20044B2401990-07-12012 July 1990 LER 90-012-00:on 900612,control Room Ventilation Emergency Air Filtration Unit Declared Inoperable.Caused by Heater Malfunction.Work Request initiated.W/900712 Ltr ML20044B0091990-07-11011 July 1990 LER 90-011-00:on 900611,diesel Fire Pump 1/2 a Out of Svc for Period Exceeding 7 Days Reporting Criteria,To Install New Suction Line.Caused by Required Maint Work.Repairs Completed & Pump Tested & Returned to svc.W/900711 Ltr ML20043H4831990-06-21021 June 1990 LER 90-010-00:on 900522,while Returning RWCU Sys to Svc, Nonregenerative HX High Temp Alarm Received,Challenging ESF Logic & Causing Group III Isolation.Caused by Leaking RWCU Check Valves.Work Requests issued.W/900621 Ltr ML20043H2931990-06-18018 June 1990 LER 90-009-00:on 900518,determined That Various Containment Vols Not Leak Rate Tested Due to Recent 10CFR50,App J Interpretation Re Licensing Design Criteria.Mod M4-1(2)-89-167 initiated.W/900618 Ltr ML20043H9521990-06-13013 June 1990 LER 90-016-01:on 900411,motor Control Ctr Relay 28/29-5 Setpoint Drift Occurred,Resulting in Analyzed Plant Condition.Caused by Utilizing Wrong Relay & Inadequate Review of GE Svc Info Ltr.Relay replaced.W/900613 Ltr ML20043E9121990-06-0707 June 1990 LER 90-006-00:on 900508,Unit 2 RCIC Declared Inoperable Due to Unstable Operation of RCIC Pump Flow Controller.Caused by Proportional Band of Controller Being Set to Respond to Changes in Flow Too Quickly.Flow controlled.W/900607 Ltr ML20043F2341990-06-0101 June 1990 LER 90-001-01:on 891208,seven Pathways Not Included in Type B & C Local Leak Rate Test Program.Caused by Misinterpretation of 10CFR50,App J Requirements.Required Vents & Test Taps Will Be installed.W/900601 Ltr ML20043F2161990-06-0101 June 1990 LER 89-024-01:on 891214,main Turbine Unexpectedly Tripped Following Isolation of Reactor Water Level Switch (Lits). Caused by Channel B Lits Having Been Previously Replaced W/ Switch That Operated Reverse function.W/900601 Ltr ML20042E4991990-04-17017 April 1990 LER 90-007-00:on 900318,ESF Actuation Occurred.Caused by Mgt Deficiency in Not Providing Sufficient Guidance for Review of Work Package After Scope Changed.New Work Package Preparation Procedures initiated.W/900417 Ltr ML20012C7231990-03-15015 March 1990 LER 90-004-00:on 900213,loss of Emergency Bus 23-1 Occurred Due to Shorted Conductor Cable While Performing Wiring Verification.Caused by Personnel Error & Improper Installation.Electric Power Supplies recovered.W/900315 Ltr ML20012C7171990-03-15015 March 1990 LER 90-003-00:on 900213,unit Diesel Generator Tripped on Overspeed Upon Manual Startup for Testing.Caused by Misadjustment of Diesel Generator Governor.Diesel Generator Equipment Reset & Governor adjusted.W/900315 Ltr ML20012B2931990-03-0505 March 1990 LER 90-002-00:on 900204,determined That Only Reactor Bldg Differential Pressure of 0.24-inch Water Vacuum Could Be Obtained,In Violation of Tech Spec Required 0.25 Inch.Caused by Testing Deficiency.Leak Paths sealed.W/900305 Ltr ML20012B2961990-03-0505 March 1990 LER 90-003-00:on 900205,determined That Leakage Rate for HPCI Sys Steam Exhaust Check Valve Exceeded Tech Spec Limits.Caused by Excessive Leakage.Check Valve Replaced W/ Mission Check Valve W/Carbon Steel springs.W/900305 Ltr ML20011E1821990-01-30030 January 1990 LER 90-002-00:on 900102,during Annual Water Sprinkler Sys Valve Position Insp,Discovered That Valve 2-4199-072 Not Cycled Per Tech Spec Surveillance Requirement 4.12.Caused by Procedural Deficiency.Procedure to Be revised.W/900130 Ltr ML19354D9431990-01-15015 January 1990 LER 89-025-00:on 891220,determined That Reactor Bldg Overhead Auxiliary Hook May Have Contacted Side of New Fuel Bundle on 891214,causing Extensive Damage.Caused by Personnel Error.Bundle Shipped Back to GE.W/900115 Ltr ML19354D9481990-01-15015 January 1990 LER 89-023-00:on 891219,identified Deficient Temporary Procedures Which Altered Intent of Original Procedure QAP 1100-7.Caused by Mgt Oversight in Preparation of Tech Spec Change.Temporary Procedures revised.W/900115 Ltr ML20005F5881990-01-0808 January 1990 LER 90-001-00:on 891208,seven Pathways Not Included in Type B & C Local Leak Rate Testing Program.Caused by Misinterpretation of 10CFR50,App J Testing Requirements.Mod of Sys to Be Performed as necessary.W/900108 Ltr ML20005G0231990-01-0202 January 1990 LER 88-020-01:on 880619,improper Valving Sequence Occurred Which Resulted in Various ESF Actuations.Caused by Inadequate Equipment out-of-svc Procedure.Procedure Revised & Training Lesson Plan developed.W/900102 Ltr ML20005E4531989-12-28028 December 1989 LER 89-022-00:on 891128,HPCI Declared Inoperable Following Unexpected Actuation of HPCI Pump Room Deluge Sys.Actuation Caused Dc Sys Grounds Due to Moisture Intrusion in Electrical Equipment.Equipment dried.W/891228 Ltr ML20005D9551989-12-22022 December 1989 LER 89-021-00:on 891124,HPCI Deluge Sys Functional Test Not Completed within Tech Spec Interval of 6 Months.Caused by Mgt Deficiency & Insufficient Procedure.Procedures Revised to Better Control Tech Specs.W/891222 Ltr ML19351A6391989-12-15015 December 1989 LER 89-020-00:on 891117,full Reactor Scram Occurred Due to Simultaneous Loss of Power to 1A & 1B 24/48-volt Distribution Panels During Panel Transfer.Caused by Personnel Error.Personnel Trained Re event.W/891215 Ltr ML19332E7581989-12-0505 December 1989 LER 89-019-00:on 891105,half Group II & III Isolation Occurred While Performing Valve Flow Check Surveillance. Caused by Leaky Isolation Valve on Transmitter.Surveillance Methods Will Be Reviewed & Procedures revised.W/891205 Ltr ML19332C7581989-11-20020 November 1989 LER 89-017-00:on 891022,discovered That 6-month Functional Test Procedure Qos 500-3 Re Functional Test for Reactor Protection Sys Electrical Assemblies Not Completed in Required Time.Caused by Mgt deficiency.W/891120 Ltr ML19327C0701989-11-0909 November 1989 LER 89-018-00:on 891012,notification Given of Potential Single Failure of Diesel Generator Voltage Regulator That Could Result in Loss of All But One ECCS Loop.Caused by Design Deficiency.New Procedure developed.W/891109 Ltr ML19327C0951989-11-0404 November 1989 LER 89-005-00:on 891012,reactor Scram Occurred Due to Turbine Stop Valve Closure.Caused by Personnel Error in That Work Analyst Overlooked Removal of Two Connections on Limit Switch.Maint Workers Immediately counseled.W/891104 Ltr ML19327C2631989-11-0101 November 1989 LER 87-009-01:on 870801,reactor Scram Occurred from Turbine Generator Load Mismatch Due to Generator Trip.Caused by Electrical Fault in Main Transformer C Phase Windings.Main Transformer Replaced w/spare.W/891103 Ltr ML19325E8261989-10-30030 October 1989 LER 87-012-01:on 870918,while Performing Qos 1600-1, Vacuum Breaker 2-1601-33E Remained Open After Testing.Caused by Binding in Test Cylinder Portion of Vacuum Breaker. Nuclear Work Requests completed.W/891030 Ltr ML19325E5921989-10-24024 October 1989 LER 87-017-01:on 870805,Group IV Isolation Received Which Resulted in Closure of HPCI Steam Supply Valves.Caused by Failed HPCI Steamline Differential Pressure Transmitter Due to Loss of Oil in Sensing cell.W/891024 Ltr ML19325E5971989-10-24024 October 1989 LER 88-003-01:on 880301,while Performing RCIC Monthly Test, RCIC Pump Could Only Achieve 400 Gpm Against Discharge Pressure of 500 Psig.Caused by Failed Hydraulic Actuator on Turbine Governor Valve.Actuator replaced.W/891024 Ltr ML19327B7901989-10-18018 October 1989 LER 89-016-00:on 890921,during Transfer of New Fuel,Fuel Assembly Released from Refueling Grapple & Fell Upon Spent Fuel Racks.Caused by Personnel Error & Procedural Deficiency.Fuel Handling Procedures Revised ML19327B0491989-10-16016 October 1989 LER 89-015-00:on 890916,during Transfer,Loss of Power to Off Gas Monitor a Caused Contacts to Open Giving Upscale Radiation Signal,Thus Starting Off Gas Timer.Caused by Inadequate Procedures.Off Gas Sys reset.W/891016 Ltr ML19325C5341989-10-0202 October 1989 LER 89-014-00:on 890910,determined That Combined Leakage Rate from All Penetrations & Valves Exceeded Tech Spec Limit.Root Cause Unknown.No Corrective Action Taken. Supplemental Rept Will Be issued.W/891002 Ltr ML18052B5541987-08-24024 August 1987 LER 87-015-00:on 870731,capacitor Failed on 1B Reactor Bldg & Refuel Floor Radiation Monitors Resulting in Safety Feature Actuation.Caused by Normal Aging.Capacitor replaced.W/870825 Ltr 1994-05-11
[Table view] Category:RO)
MONTHYEARML20029E2061994-05-11011 May 1994 LER 93-025-01:on 931205,Loop a MSIVs Exceeded TS Leakage Limit.Caused by Failure of Fastner Locking Devices.Seating Surface of Main Disc in MSIV 1A Machined & Successfully Pass LLRT on 940116.W/940511 Ltr ML17352B2501993-10-0101 October 1993 LER 93-014-00:on 930902,discovered That IRM 11 & APRM Both in Bypassed Condition W/O Half Scram Being Inserted Due to Work Practices.Irm 11 Taken Out of Bypassed Condition & Individual Involved counselled.W/931001 Ltr ML17352B2511993-10-0101 October 1993 LER 93-019-00:on 930903,RHR Pump 1A Inadvertently Started Due to Personnel Error.Pump Immediately Secured & Individual Involved Counselled on Importance of self-check.W/931001 Ltr ML20046A1801993-07-21021 July 1993 LER 92-007-00:on 930624,Toxic Gas Analyzer Inoperable Due to Personnel Error Caused by Lack of Procedural Adherence. Isolated CR Ventilation,Restarted Sample Pump & Restored CR Ventilation Sys to Outside Air suction.W/930721 Ltr ML20045H5781993-07-13013 July 1993 LER 93-013-00:on 930613,internal Electrical Fault within Main Power Transformer Tripped & Caused Reactor Scram & Unexpected Group I Isolation.Caused by Turbine Stop Valve Closure.Transformer replaced.W/930713 Ltr ML20045G7291993-07-0909 July 1993 LER 93-005-00:on 930609,numerous Alarms Received in CR, Including HPCI Turbine Rupture Disc High Pressure Alarm. Caused by Ruptured Disk,Releasing Steam/Water Mixture. Test Will Be Conducted on Rupture disks.W/930709 Ltr ML20045G0951993-07-0202 July 1993 LER 93-011-00:on 930602,HPCI Declared Inoperable in Order to Perform Qcos 2300-13.Caused by MSC Stem & Stem Gear Being Scored & Worn from Age Causing Excessive Friction.C/As Include Disassembling Gearbox Every 10 yrs.W/930702 Ltr ML20045F3321993-06-30030 June 1993 LER 93-012-00:on 930601,U-2 DG Cooling Water Pump Inoperable Due to Inadequate lubrication.U-2 DG Cooling Water Pump replaced.W/930630 Ltr ML20045F3251993-06-28028 June 1993 LER 93-007-01:on 930307,B Loop MSIV Exceeded TS Leakage Limits for Containment Isolation Valves Caused by Damaged Flexitalic Bonnet Gasket.Replaced Bonnet Gasket & Valve Successfully Retested (WR Q061987).W/930622 Ltr ML20044E6171993-05-14014 May 1993 LER 93-006-00:on 930420,Unit 2 Nso Inadvertently Started Unit 1 DG When Attempting to Start Shared (1/2) Dg.Caused by Personnel Error.Unit 1 DG Shut Down & 1/2 DG Started & Loaded successfully.W/930514 Ltr ML20044C9511993-05-0707 May 1993 LER 93-009-00:on 930408,technician Discovered That Estimate of Sample Flow for U2 Reactor Bldg Vent Sampler Flow Rate Monitor Not Calculated.Caused by Personnel Error.Technician counseled.W/930428 Ltr ML20024G6811991-04-19019 April 1991 LER 91-008-00:on 910322,reactor Bldg Ventilation Isolation Occurred.Caused by Lightning Strike.Control Room Vents Reset & Toxic Gas Sample Point a Selected.Addl Trips Associated W/ Lightning Strike Immediately reset.W/910418 Ltr ML20029C1241991-03-0808 March 1991 LER 91-005-01:on 910131,1/2 B Standby Gas Treatment Sys Autostart During RPS B Power Swap Due to an Inadequate Procedure.Nso Reset 1/2 Scram & 1/2 Groups II & III isolations.W/910306 Ltr ML20029B5901991-03-0808 March 1991 LER 91-004-00:on 910211,standby Liquid Control Sys of Unit 1 & 2 Inoperable.Caused by Inadequate Mod Testing.Engineering Dept Evaluating Data & Temporary Procedure 6589 Generated. W/910308 Ltr ML20028H7841991-01-23023 January 1991 LER 90-032-00:on 901224,1/2A Diesel Fire Pump Taken out-of- Svc on 901217 & Not Returned to Svc Before Seven Day Time Allotment Expired.Caused by Mgt Deficiency.Fire Pump Successfully Tested & Returned to svc.W/910123 Ltr ML20028H6831991-01-21021 January 1991 LER 90-034-00:on 901223,high Chlorine Concentration Caused Control Room Ventilation Manual Isolation & ESF Actuation. Caused by Instrument Error Code & Misinterpretation of Analyzer Indication.Flow reduced.W/910121 Ltr ML20028G9141990-09-28028 September 1990 LER 90-018-00:on 900829,plant Outside Design Spec for Electrical Separation Criteria for Two Redundant Safety Sys. Caused by Inadequate Engineering Review During Leads installation.W/900928 Ltr ML20044B2401990-07-12012 July 1990 LER 90-012-00:on 900612,control Room Ventilation Emergency Air Filtration Unit Declared Inoperable.Caused by Heater Malfunction.Work Request initiated.W/900712 Ltr ML20044B0091990-07-11011 July 1990 LER 90-011-00:on 900611,diesel Fire Pump 1/2 a Out of Svc for Period Exceeding 7 Days Reporting Criteria,To Install New Suction Line.Caused by Required Maint Work.Repairs Completed & Pump Tested & Returned to svc.W/900711 Ltr ML20043H4831990-06-21021 June 1990 LER 90-010-00:on 900522,while Returning RWCU Sys to Svc, Nonregenerative HX High Temp Alarm Received,Challenging ESF Logic & Causing Group III Isolation.Caused by Leaking RWCU Check Valves.Work Requests issued.W/900621 Ltr ML20043H2931990-06-18018 June 1990 LER 90-009-00:on 900518,determined That Various Containment Vols Not Leak Rate Tested Due to Recent 10CFR50,App J Interpretation Re Licensing Design Criteria.Mod M4-1(2)-89-167 initiated.W/900618 Ltr ML20043H9521990-06-13013 June 1990 LER 90-016-01:on 900411,motor Control Ctr Relay 28/29-5 Setpoint Drift Occurred,Resulting in Analyzed Plant Condition.Caused by Utilizing Wrong Relay & Inadequate Review of GE Svc Info Ltr.Relay replaced.W/900613 Ltr ML20043E9121990-06-0707 June 1990 LER 90-006-00:on 900508,Unit 2 RCIC Declared Inoperable Due to Unstable Operation of RCIC Pump Flow Controller.Caused by Proportional Band of Controller Being Set to Respond to Changes in Flow Too Quickly.Flow controlled.W/900607 Ltr ML20043F2341990-06-0101 June 1990 LER 90-001-01:on 891208,seven Pathways Not Included in Type B & C Local Leak Rate Test Program.Caused by Misinterpretation of 10CFR50,App J Requirements.Required Vents & Test Taps Will Be installed.W/900601 Ltr ML20043F2161990-06-0101 June 1990 LER 89-024-01:on 891214,main Turbine Unexpectedly Tripped Following Isolation of Reactor Water Level Switch (Lits). Caused by Channel B Lits Having Been Previously Replaced W/ Switch That Operated Reverse function.W/900601 Ltr ML20042E4991990-04-17017 April 1990 LER 90-007-00:on 900318,ESF Actuation Occurred.Caused by Mgt Deficiency in Not Providing Sufficient Guidance for Review of Work Package After Scope Changed.New Work Package Preparation Procedures initiated.W/900417 Ltr ML20012C7231990-03-15015 March 1990 LER 90-004-00:on 900213,loss of Emergency Bus 23-1 Occurred Due to Shorted Conductor Cable While Performing Wiring Verification.Caused by Personnel Error & Improper Installation.Electric Power Supplies recovered.W/900315 Ltr ML20012C7171990-03-15015 March 1990 LER 90-003-00:on 900213,unit Diesel Generator Tripped on Overspeed Upon Manual Startup for Testing.Caused by Misadjustment of Diesel Generator Governor.Diesel Generator Equipment Reset & Governor adjusted.W/900315 Ltr ML20012B2931990-03-0505 March 1990 LER 90-002-00:on 900204,determined That Only Reactor Bldg Differential Pressure of 0.24-inch Water Vacuum Could Be Obtained,In Violation of Tech Spec Required 0.25 Inch.Caused by Testing Deficiency.Leak Paths sealed.W/900305 Ltr ML20012B2961990-03-0505 March 1990 LER 90-003-00:on 900205,determined That Leakage Rate for HPCI Sys Steam Exhaust Check Valve Exceeded Tech Spec Limits.Caused by Excessive Leakage.Check Valve Replaced W/ Mission Check Valve W/Carbon Steel springs.W/900305 Ltr ML20011E1821990-01-30030 January 1990 LER 90-002-00:on 900102,during Annual Water Sprinkler Sys Valve Position Insp,Discovered That Valve 2-4199-072 Not Cycled Per Tech Spec Surveillance Requirement 4.12.Caused by Procedural Deficiency.Procedure to Be revised.W/900130 Ltr ML19354D9431990-01-15015 January 1990 LER 89-025-00:on 891220,determined That Reactor Bldg Overhead Auxiliary Hook May Have Contacted Side of New Fuel Bundle on 891214,causing Extensive Damage.Caused by Personnel Error.Bundle Shipped Back to GE.W/900115 Ltr ML19354D9481990-01-15015 January 1990 LER 89-023-00:on 891219,identified Deficient Temporary Procedures Which Altered Intent of Original Procedure QAP 1100-7.Caused by Mgt Oversight in Preparation of Tech Spec Change.Temporary Procedures revised.W/900115 Ltr ML20005F5881990-01-0808 January 1990 LER 90-001-00:on 891208,seven Pathways Not Included in Type B & C Local Leak Rate Testing Program.Caused by Misinterpretation of 10CFR50,App J Testing Requirements.Mod of Sys to Be Performed as necessary.W/900108 Ltr ML20005G0231990-01-0202 January 1990 LER 88-020-01:on 880619,improper Valving Sequence Occurred Which Resulted in Various ESF Actuations.Caused by Inadequate Equipment out-of-svc Procedure.Procedure Revised & Training Lesson Plan developed.W/900102 Ltr ML20005E4531989-12-28028 December 1989 LER 89-022-00:on 891128,HPCI Declared Inoperable Following Unexpected Actuation of HPCI Pump Room Deluge Sys.Actuation Caused Dc Sys Grounds Due to Moisture Intrusion in Electrical Equipment.Equipment dried.W/891228 Ltr ML20005D9551989-12-22022 December 1989 LER 89-021-00:on 891124,HPCI Deluge Sys Functional Test Not Completed within Tech Spec Interval of 6 Months.Caused by Mgt Deficiency & Insufficient Procedure.Procedures Revised to Better Control Tech Specs.W/891222 Ltr ML19351A6391989-12-15015 December 1989 LER 89-020-00:on 891117,full Reactor Scram Occurred Due to Simultaneous Loss of Power to 1A & 1B 24/48-volt Distribution Panels During Panel Transfer.Caused by Personnel Error.Personnel Trained Re event.W/891215 Ltr ML19332E7581989-12-0505 December 1989 LER 89-019-00:on 891105,half Group II & III Isolation Occurred While Performing Valve Flow Check Surveillance. Caused by Leaky Isolation Valve on Transmitter.Surveillance Methods Will Be Reviewed & Procedures revised.W/891205 Ltr ML19332C7581989-11-20020 November 1989 LER 89-017-00:on 891022,discovered That 6-month Functional Test Procedure Qos 500-3 Re Functional Test for Reactor Protection Sys Electrical Assemblies Not Completed in Required Time.Caused by Mgt deficiency.W/891120 Ltr ML19327C0701989-11-0909 November 1989 LER 89-018-00:on 891012,notification Given of Potential Single Failure of Diesel Generator Voltage Regulator That Could Result in Loss of All But One ECCS Loop.Caused by Design Deficiency.New Procedure developed.W/891109 Ltr ML19327C0951989-11-0404 November 1989 LER 89-005-00:on 891012,reactor Scram Occurred Due to Turbine Stop Valve Closure.Caused by Personnel Error in That Work Analyst Overlooked Removal of Two Connections on Limit Switch.Maint Workers Immediately counseled.W/891104 Ltr ML19327C2631989-11-0101 November 1989 LER 87-009-01:on 870801,reactor Scram Occurred from Turbine Generator Load Mismatch Due to Generator Trip.Caused by Electrical Fault in Main Transformer C Phase Windings.Main Transformer Replaced w/spare.W/891103 Ltr ML19325E8261989-10-30030 October 1989 LER 87-012-01:on 870918,while Performing Qos 1600-1, Vacuum Breaker 2-1601-33E Remained Open After Testing.Caused by Binding in Test Cylinder Portion of Vacuum Breaker. Nuclear Work Requests completed.W/891030 Ltr ML19325E5921989-10-24024 October 1989 LER 87-017-01:on 870805,Group IV Isolation Received Which Resulted in Closure of HPCI Steam Supply Valves.Caused by Failed HPCI Steamline Differential Pressure Transmitter Due to Loss of Oil in Sensing cell.W/891024 Ltr ML19325E5971989-10-24024 October 1989 LER 88-003-01:on 880301,while Performing RCIC Monthly Test, RCIC Pump Could Only Achieve 400 Gpm Against Discharge Pressure of 500 Psig.Caused by Failed Hydraulic Actuator on Turbine Governor Valve.Actuator replaced.W/891024 Ltr ML19327B7901989-10-18018 October 1989 LER 89-016-00:on 890921,during Transfer of New Fuel,Fuel Assembly Released from Refueling Grapple & Fell Upon Spent Fuel Racks.Caused by Personnel Error & Procedural Deficiency.Fuel Handling Procedures Revised ML19327B0491989-10-16016 October 1989 LER 89-015-00:on 890916,during Transfer,Loss of Power to Off Gas Monitor a Caused Contacts to Open Giving Upscale Radiation Signal,Thus Starting Off Gas Timer.Caused by Inadequate Procedures.Off Gas Sys reset.W/891016 Ltr ML19325C5341989-10-0202 October 1989 LER 89-014-00:on 890910,determined That Combined Leakage Rate from All Penetrations & Valves Exceeded Tech Spec Limit.Root Cause Unknown.No Corrective Action Taken. Supplemental Rept Will Be issued.W/891002 Ltr ML18052B5541987-08-24024 August 1987 LER 87-015-00:on 870731,capacitor Failed on 1B Reactor Bldg & Refuel Floor Radiation Monitors Resulting in Safety Feature Actuation.Caused by Normal Aging.Capacitor replaced.W/870825 Ltr 1994-05-11
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20217A9931999-09-30030 September 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data SVP-99-204, Monthly Operating Repts for Sept 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With1999-09-30030 September 1999 Monthly Operating Repts for Sept 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With ML20217A1691999-09-22022 September 1999 Part 21 Rept Re Engine Sys,Inc Controllers,Manufactured Between Dec 1997 & May 1999,that May Have Questionable Soldering Workmanship.Caused by Inadequate Personnel Training.Sent Rept to All Nuclear Customers ML20212J0501999-09-21021 September 1999 Safety Evaluation Re Licensee Implementation Program to Resolve USI A-46 at Plant,Per GL 87-02,Suppl 1 SVP-99-179, Monthly Operating Repts for Aug 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With1999-08-31031 August 1999 Monthly Operating Repts for Aug 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With ML20210L8661999-08-0202 August 1999 Safety Evaluation Accepting License 60-day Response to GL 96-05, Periodic Verification of Design-Basis Capability of Safety-Related Movs SVP-99-155, Monthly Operating Repts for July 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With1999-07-31031 July 1999 Monthly Operating Repts for July 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With SVP-99-148, Monthly Operating Repts for June 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With1999-06-30030 June 1999 Monthly Operating Repts for June 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With ML20196H8621999-06-30030 June 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept ML20195K1481999-06-16016 June 1999 Safety Evaluation Authorizing Relief Request RV-23A for Duration of Current 10 Yr IST Interval on Basis That Compliance with Code Requirements Would Result in Hardship Without Compensating Increase in Level of Quality & Safety SVP-99-123, Monthly Operating Repts for May 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With1999-05-31031 May 1999 Monthly Operating Repts for May 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With ML20195B2591999-05-19019 May 1999 Rev 66a to CE-1-A,consisting of Proposed Changes to QAP for Dnps,Qcs,Znps,Lcs,Byron & Braidwood Stations SVP-99-104, Monthly Operating Repts for Apr 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With1999-04-30030 April 1999 Monthly Operating Repts for Apr 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With SVP-99-102, Summary Rept of Changes,Tests & Experiments Completed, Covering Period 990201-0430. with1999-04-30030 April 1999 Summary Rept of Changes,Tests & Experiments Completed, Covering Period 990201-0430. with ML20205Q5291999-04-16016 April 1999 SER Concluding That Quad Cities Nuclear Power Station,Unit 1,can Be Safely Operated for Next Fuel Cycle with Weld O2BS-F4 in Current Condition Because Structural Integrity of Weld Will Be Maintained ML20205J6011999-04-0707 April 1999 Safety Evaluation Accepting Proposed Merger of Calenergy Co, Inc & Midamerican Holdings Co for Quad Cities Nuclear Power Station,Units 1 & 2 SVP-99-071, Monthly Operating Repts for Mar 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With1999-03-31031 March 1999 Monthly Operating Repts for Mar 1999 for Quad Cities Nuclear Power Station,Units 1 & 2.With ML20205C5671999-03-19019 March 1999 Simulator Four-Yr Certification Rept ML20207D2341999-03-0101 March 1999 Post Outage (90 Day) Summary Rept, for ISI Exams & Repair/Replacement Activities Conducted 981207-1205 ML20204B1571999-02-28028 February 1999 Monthly Operating Repts for Feb 1999 for Quad Cities,Units 1 & 2.With SVP-99-021, Quarterly Summary SER of Changes,Tests & Experiments Completed, Covering Period of 981101-990131,IAW 10CFR50.59 & 10CFR50.71(e).With1999-01-31031 January 1999 Quarterly Summary SER of Changes,Tests & Experiments Completed, Covering Period of 981101-990131,IAW 10CFR50.59 & 10CFR50.71(e).With ML20205D1311998-12-31031 December 1998 1998 Decommissioning Funding Status Rept for Yr Ending 981231 for Quad Cities Nuclear Power Station,Units 1 & 2 ML20205M7061998-12-31031 December 1998 Unicom Corp 1998 Summary Annual Rept. with SVP-99-007, Monthly Operating Repts for Dec 1998 for Quad Cities Nuclear Power Station,Units 1 & 2,IAW GL 97-02 & TS 6.9.With1998-12-31031 December 1998 Monthly Operating Repts for Dec 1998 for Quad Cities Nuclear Power Station,Units 1 & 2,IAW GL 97-02 & TS 6.9.With ML20196C8391998-11-30030 November 1998 Rev 0 to GE-NE-B13-01980-030-2, Assessment of Crack Growth Rates Applicable to Induction Heating Stress Improvement (IHSI) Recirculation Piping in Quad Cities Unit 1 SVP-98-364, Monthly Operating Repts for Nov 1998 for Quad Cities Nuclear Power Station,Units 1 & 2.With1998-11-30030 November 1998 Monthly Operating Repts for Nov 1998 for Quad Cities Nuclear Power Station,Units 1 & 2.With ML20196G1241998-11-30030 November 1998 COLR for Quad Cities Unit 1 Cycle 16 ML20196D9651998-11-30030 November 1998 Safety Evaluation Supporting Relief Requests CR-21 & CR-24, Respectively.Relief Request CR-23,proposed Alternative May Be Authorized,Per 10CFR50.55a & Relief Request CR-22 Was Withdrawn by Licensee ML20196C8731998-11-30030 November 1998 Rev 0 to GE-NE-B13-01980-30-1, Fracture Mechanics Evaluation on Observed Indications at Two Welds in Recirculation Piping of Quad Cities,Unit 1 Station ML20196A9761998-11-20020 November 1998 Safety Evaluation Re Licensee 180-day Response to GL 95-07, Thermal Binding of Safety-Related Power-operated Gate Valves ML20196A4191998-11-19019 November 1998 Safety Evaluation Accepting QA TR CE-1-A,Rev 66 Re Changes in Independent & Onsite Review Organization by Creating NSRB SVP-98-346, Monthly Operating Repts for Oct 1998 for Quad Cities Nuclear Power Station,Units 1 & 2.With1998-10-31031 October 1998 Monthly Operating Repts for Oct 1998 for Quad Cities Nuclear Power Station,Units 1 & 2.With SVP-98-358, Summary Rept of Changes,Tests & Experiments Completed, Including SEs Covering Period on 980716-1031.With1998-10-31031 October 1998 Summary Rept of Changes,Tests & Experiments Completed, Including SEs Covering Period on 980716-1031.With SVP-98-326, Monthly Operating Repts for Sept 1998 for Quad Cities Nuclear Power Station,Units 1 & 2.With1998-09-30030 September 1998 Monthly Operating Repts for Sept 1998 for Quad Cities Nuclear Power Station,Units 1 & 2.With ML20153D0191998-09-18018 September 1998 Part 21 Rept Re Defect in Gap Conductance Analyses for co- Resident BWR Fuel.Initially Reported on 980917.Corrective Analyses Performed Demonstrating That Current Operating Limits Bounding from BOC to Cycle Exposure of 8 Gwd/Mtu ML20153C6771998-09-17017 September 1998 Part 21 Rept Re Defect Relative to MCPR Operating Limits as Impacted by Gap Conductance of co-resident BWR Fuel at Facilities.Operating Limit for LaSalle Unit 2 & Quad Cities Unit 2 Will Be Revised as Listed ML20151T2711998-09-0404 September 1998 Safety Evaluation Accepting Licensee Response to NRC Bulletin 95-002 ML20151Y7261998-08-31031 August 1998 Monthly Operating Repts for Aug 1998 for Quad Cities Nuclear Power Station ML20237E2331998-08-21021 August 1998 Revised Pages of Section 20 of Rev 66 to CE-1-A, QA Topical Rept ML20151Y7301998-07-31031 July 1998 Revised MOR for Jul 1998 for Quad Cities Nuclear Power Station,Units 1 & 2 ML20237A6251998-07-31031 July 1998 Monthly Operating Repts for July 1998 for Quad Cities Nuclear Power Station,Unit 1 & 2 SVP-98-328, Summary Rept of Changes,Tests & Experiments Completed, Including SEs Covering Period of 971001-980715,per 10CFR50.59 & 10CFR50.71(e).With1998-07-15015 July 1998 Summary Rept of Changes,Tests & Experiments Completed, Including SEs Covering Period of 971001-980715,per 10CFR50.59 & 10CFR50.71(e).With SVP-98-249, Monthly Operating Repts for June 1998 for Quad Cities Nuclear Power Station,Units 1 & 21998-06-30030 June 1998 Monthly Operating Repts for June 1998 for Quad Cities Nuclear Power Station,Units 1 & 2 SVP-98-215, Monthly Operating Repts for May 1998 for Quad Cities Nuclear Power Station Units 1 & 21998-05-31031 May 1998 Monthly Operating Repts for May 1998 for Quad Cities Nuclear Power Station Units 1 & 2 ML20247N6281998-05-19019 May 1998 Rev 2 to COLR for Quad Cities Unit 2 Cycle 15 ML20216C0561998-04-30030 April 1998 Safe Shutdown Rept for Quad Cities Station,Units 1 & 2, Vols 1 & 2.W/22 Oversize Figures SVP-98-176, Monthly Operating Repts for Apr 1998 for Quad Cities Nuclear Power Station,Units 1 & 21998-04-30030 April 1998 Monthly Operating Repts for Apr 1998 for Quad Cities Nuclear Power Station,Units 1 & 2 ML20217D0281998-04-22022 April 1998 Part 21 Rept Re Additive Constants Used in MCPR Determination for Siemens ATRIUM-9B Fuel by Core Monitoring Sys Were Found to Be non-conservative.SPC Personnel Notified All Customers w/ATRIUM-9B Lead Test Assemblies ML20217G3951998-04-0808 April 1998 TS 3/4.8.F Snubber Functional Testing Scope Quad Cities Unit 2 TS (Safety-Related) Snubber Population 129 Snubbers SVP-98-128, Monthly Operating Repts for Mar 1998 for Quad Cities Nuclear Station Units 1 & 21998-03-31031 March 1998 Monthly Operating Repts for Mar 1998 for Quad Cities Nuclear Station Units 1 & 2 1999-09-30
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.. - 'N Common':ealth Edison i'~ ,) ound Cit:s Nuccar Power Statior.
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'( c"' % 22710 206 Avenue North 9 ' ,a \ / Cordova. N:nos 61242 9730
'd Telephone 309!654 2241
- RLB-89-233 s
t October 19, 1989 U. S. Nuclear Regulatory Commission -
Document Control. Desk Hashington, DC 20555
Reference:
Quad Cities Nuclear Power Station .
Docket Number 50-254, DPR-29, Unit One L Enclosed is Licensee Event Report (LER) 89-016, Revision 00, for Quad Cities Nuclear Power Station, This report is submitted in accordance with the requirements of the Code of Federal Regulations, Title 10, Part 20.405(a)(1)(iv), which requires the~
licensee to make a report in writing within 30 days of the occurrence of any incident for which notification is required by 10 CFR 20.403.
Respectfully, COMMONHEALTH EDISON COMPANY QUAD CITIES N'JCLEAR POWER STATION f .ptG R. L. x
- Station Manager RLB/MJB/ad Enclosure ;
1 cc: R. Stols -
R. Higgins INPO Records Center p I. NRC Region III - i i
\ ,
8911130331 891018 DR ADoCK 0500 54 !%IC T /?os] jigg;
i i LICENSEE EVENT REPORT (LER) ,
I,' Facility.4ame,(1) ,
O!cket Number (2) Pane f3) e g Cittet' unit one of El Di of 01 21 El 4 1 I off oI a Title (4) New Fuel Assembly Dropped in Fuel Pool When Refuel Bridge Fuel Grapple Released Ove to Personnel Error and lack of Procedural Guidance Event Data ft) LER Number (6) Renott Date (7) Other Facilities Involved fal Month Day Year Year / sequential // ('evision Month Day Year Facility Names Docket Numberfs) p/j/j/
// NJmber j//j/p/ Number 01 si of 01 of I 1 l
~~~ ~~~ 1 0] 9 fl 1 al 9 El 9 011 l6 0 l0 1 10 Il B al 9 01 El el 01 of I l <
I TH!s REPORT IS SuSMITTEC PURSUANT TO THE REQUIREMENTS OF 10CFR (Check one or more of the followino) (11) 1 20.402(b) ._. 20.405(c) 50.73(a)(2)(iv) , 73.71(b)
P0wtR 20.40$(a)(1)(1) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c)
LEVEL 20.405(a)(1)(11) 50.36(c)(2) , 50.73(a)(2)(vii) _ Other (specify (to) ol0! O __ 20.405(a)(1)(111) 50.73(4)(2)(1) 50.73(a)(2)(v111)(A) in Abstract
//////////////////////,//// X. 20.405(a)(1)(tv) 50.73(a)(2)(11) _ 50.73(a)(2)(viii)(B) below and in
/////////////////////j///// _ 20.405(a)(1)(v) 50.73(a)(2)(111) 50.73(a)(2)(x) Text)
LICENSEE CONTACT FOR THIS LER (12)
Name TELEPHONE NUMBER AREA CODE
.lohn Lechmaier. Technical staff Enoineer. Ext. 2174 3 10 19 61 51 4l -l 21 ?! 41 COMPLETE ONE LINE FOR EACH COM F AILURE DESCRIBED IN THis REPORT (13)
CAUSE SYSTEM COMPONENT MANuFAC- REPORTABLE CAust SYSTEM COMPONENT MANuFAC- REPORTABLE TURER TO NPROS TURER TO NPRD1 l l l l l i l i l l l l l l l l 1 l I l l l 1 1 1 I i i SUPPLEMENTAL REPORT EXPECTED (14) Expected Month I Day I Year Submission lYet (If yet. comolete EXPECTED SUBMIS$10N JATE) X l NO I l l ABSTRACT (Limit to 1400 spaces, i.e. approximately fifteen single space typewritten lines) (16)
On September 21, 1989, Unit One was in the SHUTDOWN mode with all fuel removed from the reactor vessel.
At 1410 hours, during the transfer of new fuel from the new fuel storage vault to the fuel pool, fuel assembly LYT 191 was released from the refueling grapple and fell vocn spent fuel racks.
The grapple control switch was inadvertently left in the " release" position after attempting to unlatch. The unlatching failure was due to the adjacent assembly not being fully seated. The cause of fuel assemDly drop was a combination of personnel
. error and procedural deficiency.
Corrective action included a refuel bridge hoist circuitry modification to prevent raising a fuel assembly'with the grapple control switch in " release." The fuel handling procedures were revised to assure proper fuel assembly seating and proper positioning of the grapple control switch.
This report is submitted to comply with the requirements of 10CFR20.405(a)(1)(iv).
2295H/06822
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, _'. LICENSEE EVENi REPDAT ILER) TEXT CONTINUAT!0N Form Rev 2.0 FACILITY NAftE, (1) l ' DOCKET huMBER (2) Lta utseLR ts) Pace f3) _
Year /// seguential
/g/,/ Revision p,/p/
/ humber /// Number
: Guad Citiet Unit One 0 IEl0l010 l 21 51 4 al9 - 0 I) !6 - O l0 of 2 0F of B TEXT Energy Industry Identification system (E!!s) codes are identified in the text as (XX)
' PLANT AND SYSTEM IDENTIFICATION:
General. Electric - Boiling Water Reactor - 2511 MHt rated core thermal power.
. EVENT IDENTIFICA.*?ON: New Fuel Ass'embly Dropped in Fuel Pool When Refuel Bridge Fuel Grapple Released Due to Personnel Error and Lack of Procedural Guidance A. CONDITIONS PRIOR TO EVENT:
Unit: One Event Date: September 21, 1989 Event Time: 1410 i Reactor Mode: 1 Mode Name: SHUTDOWN Power Level: 00%
This. report was initiated by Deviation Report D-4-1-89-080.
Shutdown Mode (1) - In this position, a reactor scram is initiated, power to the control rod drives is removed, and the reactor protection trip systems have been
>deenergized for 10 seconds prior to permissive for manual reset.
B. DESCRIPTION OF EVENT:
On September 21, 1989, Unit One was in the SHUTDONN n. ode with all fuel removed from the reactor [RCT) vessel [VSL). Operations were in progress to move-new fuel from the new fuel storage vaults (RK) into the Unit One fuel storage pool racks [RK).
This consisted of moving the new fuel from the new fuel storage vaults to the Unit One fuel prep machines [FHM) (in the fuel pool) with the overhead trane [CRN), and then transferring the fuel to the fuel racks with the Unit One refuel bridge
[DF)[FMB). This was being performed per QFP 200-3, Transfer of New Fuel from
.Either the New Fuel Storage Vault or the New fuel Inspection Stand [FHM) to the Fuel Pool, and per QFP 150-2, Refueling Platform Operation.
At approximately 1400 hours, new fuel assembly LYT 191 was being moved from the Unit One #1 fuel prep machine [FHM] to location 03N-35H in the fuel rack. The fuel handler (FH) moved the fuel assembly over the target location and lowered it into r the rack until the slack cable [CBL) Itght [IL) came on. The slack cable light indicates there is <50 lbs. of weight on the cable. The FH also visually verified that the fuel assembly appeared to be fully seated. The FH then put the grapple
[ HOI] control [HC) switch [HS) to the " Release" position to release the fuel assembly. However, the graople engaged light remained lit which indicated that the grapple's opposing J hooks had not opened and the fuel assembly was still latched.
The FH operated the grapple control switch a few more times, then lifted the fuel l
i assembly slightly, rotated the mast [FMH) back and forth slightly, and lowered the l ussembly again. These are actions normally taken when seating a fuel assembly.
l Further operation of the grapple control switch failed to cause the fuel grapple I engaged light to go out.
l.
l l- 2395H/06822 e
LifENSEE EVENT REPM T iLER) TEXT CONTINUATION Form Rav 2.0. I
* ' LER NLmaER f 61 Pana f31
;. FAC{LITv'tM (1) ' D'OCKET huPSER (2). . ]
,- uar sequ:ntial Revision
,s N g .r a~r a
numd cittas unit Gna e i t I e I e I o 1 21 E l 4 aie - oI1 i6 . oIo of 3 or 01_,3 ftxT: Energy Industry Identification system (t!!s) codes are identified in the text as [XX)
At this point, the FH informed the fuel Handling Foreman (FHF) of the problem. The C FHF suspected that there may be an obstruction from the adjacent assembly which could be avoided if the assembly was rotated. The FHF instructed the FH to raise the fuel assembly out of the fuel rack, rotate it 90 degrees, and lower it back j into the fuel rack. The FH raised the assembly jus,' clear of the fuel rack, -
rotated it 90 degrees, and started to lower it. The bottom of the fuel assembly l contacted the top of the fuel rack and the fuel grapple opposing J hooks opened I unexpectedly, releasing the fuel assembly. The fuel assembly tipped away from the mast and was observed by the FHF and another FH to fall slowly across irradiated i fuel and stay in the position it first landed. Immediately thereafter, at 1410
. hours, the three FH present and the FHF moved to the southwest corner (near Unit l One exit) of the refuel floor as a precaution, although no radiation alarms were l annunciating. At this time, the FHF notified the Shift Engineer (SE), the Radiation Protection Department, and the L.ead Nuclear Engineer (LNE). The LNE assigned a Nuclear Engineer (NE) to notify an Operating Engineer (OE), and >
proceeded to the refuel floor.
The Radiation Protection Department dispatched a Radiation Technician (RT) and a Radiation Protection Foreman (RPF) to the refuel floor. They also notified a l
Health Physicist (HP) who called the refuel floor and questioned the FHF concerning E his location and-any Area Radiation Monitor (ARM) alarms (RA) or personal dosimetry (MON) indications'of abnormal dose rates. After being informed of the FHF's location on the refuel floor and of the absence of ARM alarms and dosimetry indications of abnormal dose levels, the HP instructed the FHF to remain where he was and to wait for the RT. A RPF also initiated a search of the GSEP manual for ,
possible classifications and determined that none were appropriate.
The SE. notified the Shift Control Room Engineer (SCRE) and instructed him to start both trains of Standby Gas Treatment (SBGT) (BH3 as a precaution. QAP 1290-1, Reporting Requirements Procedure, Q0A 800-1. Irradiated Fuel Damage While Refueling, and the GSEP manual were all checked for applicability by the SE. It was determined that the conditions were such that it was not necessary to classify the event as a GSEP, no immediate off-site notifications were necessary, and further verification of no change on refuel floor radiation levels was sufficient immediate corrective action. All ARMS, as well as the radiation monitors specific to tne refuel floor and the Reactor Building Ventilation System (VA), were checked and no abnormal activity was noted.
At approximately 1415 hours, the RT, RPF, LNE and OE arrived on the refuel floor. I 1
The RT verified that radiation levels on the refuel floor were normal and no Continuous Air Monitor (CAM) alarms (RA) were annunciating, and thus, it was safe to approach the fuel pool. The dropped fuel assembly and the irradiated fuel it fell on were visually examined in place from the bridge and the floor for signs of fuel damage. No damage was observed. The FHF, OE, and LNE then engaged in a i ten-minute discussion of their concerns about the situation. This discussion included the abnormality of the situation, the concern that although the pool was not critical now, they could not assure this configuration would not result in criticality at some time iri the future, and the concern with having the weight of the assembly on irradiated fuel. Based on these concerns, the OE determined that the situation warranted immediate action. The decision was made to rely on the
! expertise available on the floor (the LNE and OE have Senior Reactor Operator [SRO) -
Licenses, and the FHF has a Limited SRO License) and proceed with righting the fallen assembly.
2295H/06822 i
. ~ _ _ _ . ._. _
( .
Lif tuitt EVENT ktPoti f Ltti Ttxf c0NTIMuifiON Form Rev Le FAc1LITY nap (,(1)
' DOCKET NupttR (2) Lta utseta ts) Pane f31
- v.ar s..u.nt m a.,iii n
. y/j
// Number j/y/
7 Mumbe r ._
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.e. Gund cities unit one o I s I o 1 o I o l 21 si e aie -
Al1 l a - o1o 0F TtxT Energy Industry Id.ntification system (E!!s) codes ar. identifictj in the t.xt as [xx) 6 The FH previously assigned to the fuel prep machine was dispatched to the refuel
' bridge and instructed to pick up the dropped assembly with the J hook on the auxiliary hoist and put it in the empty fuel prep machine per the previous discussion. The assembly was righted with the appropriate bridge movement to assure that there was no sliding or swinging as it came up. As the FH was transporting the assembly to the prep machine, it was realized that it could not be put in the fuel prep' machine with the auxiliary hoist [ HOI] due to the position of the auxiliary hoist [ROI] in relation to the main hoist. Therefore, it was j i
necessary to put the assembly.in a nearby open fuel rack space. ;
When the Station Manager was notified of the situation, a meeting was held between the Assistant Superintendent of Operations (AS0) and the Station Manager to discuss the situation. The decision was made to cease fuel mosement until identification
.of root cause could be made. The ASO made a call to the refuel bridge and )
instructed the OE to cease all fuel movement. The OE informed him of the current !
status of the dropped fuel assembly, and with the agreement of the ASO, the ~!
assembly was put in.the nearest cepen fuel rack.
i The FH, after placing the dropped assembly-in the fuel rack, proceeded to test the fuel grapple interlocks [IEL) on the dummy fuel bundle, at the FHF's direction, to verify operability of the grapple. After successfully completing the test, he
. moved a fuel assembly that had been previously placed in the fuel prep machine to its assigned location in the fuel rack, at the FHF's direction. The FHF believed >
that only the dropped assembly was not to be moved again. After this move, all .
fuel movement was ceased.
At 1605 hours, a 24-hour. Emergency Notification System (ENS) phone call to the NRC per.10CFR20.403 (greater than $2,000 damage to licensed material) was made.. This notification was based on the assumption that the new fuel assembly would have to be replaced, regardless of actual damage. At about 1500 hours, the event was l declared a Potentially Significant Event,-and, at 1635 hours, Nuclear Operations t was notified. At 1900 hours, the Control Room started recording refuel floor ARMS !
and refuel floor radiation monitor readings every two hours.
Further immediate responses included:
e Radiation Protection performed a refuel floor air sample for noble gases, particulates, and halogens, refuel pool samples for nuclide concentrations, noble gases, and gross activity, and dose surveys of other areas of the ;
Reactor Building, and placed an ARM near the unit one fuel pool heat exchangers (HX). All results were normal.
- The bridge interlocks were verified and documented again later on Septemoer 21, 1989. i I e A 24-hour notification to Illinois Department of Nuclear Safety (IDNS) was ;
made on September 22, 1989. IDNS indicated a follow-up telegram would not be necessary. 1 l
W l l 4
2N5H/0682Z I j L , _. ~ _ _ - . . _ _- __ __ .. _ _
i
LitEhi[[ EVENT REPORT fLER) T[rf CGNith_uAT!ou Form Rav 2.0 d '
DOCKET NUMBER (2) LER WLBGER f 6) Pana f3)
FACILITY N,M % (1)
Year ///
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//
sequential humber
/jj f
//
///
Revision Mumher 3 - cities unit one o I s I o I o I o i 21 El 4 al9 - oI1 Is - oIo of 5 of_ ,.ALA Ttxt Energy Induttry Identification system (E!!s) codes are toontified in the text as (xXI
- A visual inspection of a portion of the affected area of the fuel pool was performed on the morning of September 22, 1989, with a television camera (TVC]
to verify no immediately detectaole failure. This did verify that the assembly adjacent to the target position for the dropped assembly was sitting up about six incnes for no perceivable reason.
*' The original High Density Fuel Rack Analysis was reviewed and one fuel assembly laying horizontally on top of the fuel rack with fuel in the rack was determined to have been analyzed for sufficient margin to criticality.
- As of the afternoon of September 22, 1989, all use of the refuel grapple was restricted .as well as prohibiting fuel movement.
There were no other structures, systems or components inoperable or degraded at the start of this event which could have contributed to the event.
C. APPARENT CAUSE OF EVENT:
This event is being reported in accordance with 10CFR20.405(a)(1)(iv), which requires the licensee to make a report in writing within 30 days of the occurrence of any incident fer which notification is required by 10CFR20.403. .
The normal procedure for fuel movement as described in QFP 150-2, Refueling Platform Operations, is to lower the fuel grapple onto the fuel assembly, put the grapple control switch to " engage," verify the engaged light is lit, rotate the hoist slightly back and forth, raise the assembly out of the rack, transport the fuel assembly, lower the assembly into the rack until the slack cable light is lit, put the grapple control switch to " release," see the engaged light go off, and raise the hoist.
This time, at the point where the engaged light should have gone out, the grapple remained engaged and the light stayed on. Investigation showed'that the bundle next to it was not fully seated. As a result, the grapple came in contact with the adjacent fuel assembly and could not be lowered far enough to allow the grapple's oppostrig J hooks to clear the assembly handle. After repeated attempts to release the assembly, the FH raised the assembly to rotate it. The grapple control switch was inadvertently left in "relea:e" as he raised the assembly. As it was lowered after it was rotated, the bottom of the assembly (lower tie plate) contacted the top of the rack. This is not an unusual occurrence due to the small difference in size be+ ween the fuel assembly and the high density fuel rack opening. Hith the lower tie plate of the assembly resting on top of the rack, the weight of the assembly came off of the grapple, such that the grapple's opposing J hooks cleared the assembly handle. Since the grapple control switch was still in the " release" position, the grapple released the assembly, i
22?5H/06822 l l
- LICENs[E EVENT REPORT (LER) TEXT'CoNTINUATIoM Form Rev 2.0
'* Pane f21 FACILITY NAME (1), '00cKET NUPSER (2) LtR MuMa[R is)
Year /// sequential Revision
* /jI#/ Namuber /)// Number ff
'b nuad Etttes unit one oIsIeieio 1 21 11 4 al9 - o11 Is - oIo of 6 or of a TEXT Energy Industry Identification system (Ells) codes are identified in the text as (xX) ,
The root cause for this event is a combination of personnel error and lack of I procedural guidance. It appears that during the attempts to get the fuel grapple to release, the FH lost track of the positt>n of the grapple control switch, and did not verify that it was in the engage" position prior to lifting the fuel assembly'to rotate it. Also, the FH appeared to place a large amount of emphasis on the green light which indicates the position of the grapple's opposing J hooks.
As a result, the FH felt that he was okay as long as the green light was lit. This green light indicates the position of the grapple's opposing J hooks (released or engaged), and not the position of the engage switch. The fact that there was no procedural guidance for attempting to release a fuel assembly that cannot be released is a contributing cause for this event.
On September 29, 1989, the adjacent fuel assembly was removed from its location in order to determine why it had not fully seated. A piece from a previously cut up Local Power Range Monitor (LPRM) [IG)(MON) was found lodged in the bottom of the i rack. The piece was removed from the location, the fuel assembly was returned, and l was then found to seat properly. The piece of LPRM was approximately nine inches l' in length. A total of 330 LPRM strings were cut up for disposal between January and June of 1989. However, it cannot be determined how this one piece fell into .
the bottom of the rack.
I It is not uncommon for irradiated fuel at higher exposures to not fully seat due to L channel bowing. However, this problem does not exist with new fuel, so a new fuel ,
assembly should always seat properly. Observance of the digital readout of the -
l mast height can be used to determine if a fuel assembly is properly seated.
However, no procedural requirement existed to direct the FH to observe the digital l
readout to verify proper seating of the fuel assembly prior to releasing it. It would have been difficult for the FH standing on tne refuel bridge to recognize visually that the fuel assembly was not fully seated, but the digital readout would have indicated that the mast was not at the proper height for a fully seated fuel assembly.
1 L Two other concerns were identified in this event, neither being factors which l resulted in the dropping of the fuel assembly. The first concern regards the i' retrieval of the dropped fuel assembly. Although the decision to pick up the I dropped fuel assembly and restore it to a normal configuration was made with a full understanding of the situation by fully qualified people, communications should have been established with readily available upper station management immediately.
In addition, there is no procedure which specifically addresses this situation.
The other concern regards the single fuel assembly moved from the fuel prep machine after upper station manugement made the decision to cease fuel movement. This was caused by missed communication. It appears that the decision was communicated to the OE on the refuel floor, but the FHF understood only that the dropped fuel assembly was not to be moved. The FHF did not realize that all fuel movements were to cease. It wasn't until after the fuel assembly had been moved from the fuel prep machine to the fuel rack that he was again informed to cease all fuel moves.
3395H/06822
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. ~ .
L. A Litthif t EMNT REPORT f LER1 TirT coNTtuuATION Form Rev 2.0 FACILIN NAME- (1) DOCKET NUMBER (2) .
Ltt Ntsnta tal Pane f21
, / Year /
,/g/ sequential // Revision
/// Number j///g/ Number w cities unit one o I s I o I o f o l 21 11 e aie - oi1 Is - oIo of 7 of of a TEXT Energy Industry identification system (E!!s) codes are identified in the text as [XXI ,
D. SAFETY ANAL.YSIS OF EVENT:
The weight of the fuel assembly was being supported by its lower tie plate resting on the rack in the fuel pool when it fell. Thus, it fell slowly and did not bounce 3 or roll. All initial observations (visual, air samples, dose rates, fuel pool samples, ARM indications, CAM indicstions) indicated there was no irradiated fuel damage. Subsequent examination of the dropped fuel assembly, after removal from the fuel pool, revealed minor indentations to the fuel channel; however, no damage was observed to the fuel rods. Fuei sipping of the 32 fuel assemblies which encompassed the region where the dropped assembly fell revealed no damage. For this particular event to occur, the weight of the fuel assembly must have come off the opposing grapple J hooks, therefore, the assembly was being supported by the fuel rack. Consequently, the length of the fall was limited to the length of the fuel assembly. Both trains of SBGT were available throughout the event. The configuration of one fuel assembly lying horizontally on the fuel in the fuel racks .
has been analyzed for sufficient margin to criticality and a fuel assembly drop while loading the core has been analyzed. Thus, the safety consequences of this event were minimal.
E. CORRECTIVE ACTIONS:
Several corrective actions have been taken as a result of this event. Modification M-4-1-89-152 was completed on September 27, 1989, to the Unit One refuel bridge. '
This modification installed an interlock which prevents raising the main grapple hoist with the grapple control switch in the release position unless the hoist is
. unloaded. Fuel movement with the Unit Two refuel bridge is prohibited until modification M-4-2-89-152 (which installs the s&me interlock to the Unit Two refuel bridge) is completed (NTS 2542008908003). Also, the fuel handling procedures have been updated with additional notes and steps to verify that the grapple control switch is in the engaged position at all times while fuel (or a blade guide) is loaded, unless releasing the fuel assembly (or blade guide) at its fully seated position in the core or in the fuel storage pool. The updated procedures also now require using the main grapple hoist position indication to verify proper seating l of a fuel assembly prior to attempting to release it. If proper indication is not
. observed, the FH is to notify the FHF. Additional revisions will be made to the l
Fuel Handling procedures to provide tolerances to the FHF on the digital height read out for a fully seated bundle (NTS 2542008908001). In addition,'a new procedure, QFP 110-1, Refuel Bridge Grapple Fails to Release, has been implemented. This procedure details the steps to be taken when the refuel bridge grapple does not release a fuel assembly or a blade guide.
This event was discussed with all the FHs. The FHs were trained on using the digital readout of mast height to verify that a bundle is properly seated. The training also included operation of the grapple control switch and the indication of the engaged light for grapple position.
l The individuals involved in the missed communication have had the importance of conscientious communications emphasized to them.
On September 29, 1989, the dropped fuel bundle was pulled from the pool and dechanneled for inspection. Inspection of the channel revealed several inder.tations from W bail handles on which the fuel assembly fell. The deepest indentation was 37 mils in depth. Examination of the fuel rods revealed no damage.
2295H/06822 l
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J
. LittNitt [VthT REPonT (LER) ftri CONTIhuAT1oM Form Rav 2.o FACJLITY %W-(l) 60CKET NUPS(R (2) ,.
tra uunata (6) Pana it) ,
'> Year ///
ppp sequ;ntial p//
/pp Revision e /// Number /// humber nund titten unit one o I a i o I o I o I 21 El 4 al9 - oI1 I6 - oIo of a oF of a
, TEXT tnergy Industry Identification system (E!!s) codes are identified in the text as [xx)
Four bundles were visually examined by a General Electric representative. The i bundles selected for examination included the three bundles impacted the hardest by the fallen fuel assembly based upon the indentation depth obtained from the fallen fuel. assembly. These three bundles were impacted near the lower end of the fallen fuel assembly. One additional bundle was selected to include the bundle impacted the hardest by the upper end of the fallen fuel assembly. These four selected fuel .
bundles (LYD444, LYD453, LYO383, LYD429) were dechanneled and their fuel rods were '
examined for evidence of bowing or damage by impact forces. Examination of the rods and other bundle parts (upper tie plates, channel fasteners, spacers, etc.)
revealed no damage.
The two rows of 16 fuel bundles (32 total) which encompassed the region where the fuel assembly fell were sipped for indication of fuel damage. The sipping of these fuel assemblies was completed on October 2, 1989. The results revealed no .
Indication of leakage of any fuel assemblies.
Although no apparent damage has resulted to any of the irradiated fuel, 12 of the 32 potentially impacted fuel assemblies will be discharged instead of reloaded for use in the upcoming fuel cycle. Two of these fuel assemblies have four cycles of ~
exposure and seven have three cycles of exposure. These nine fuel assemblies will be discharged since they may be replaced with other fuel assemblies (which were to be discharged) with no effect on the upcoming cycle length. Three remaining fuel assemblies with two cycles of exposure will be discharged since they were the hardest impacted by the fallen fuel assembly. One remaining fuel assembly (not one of the 32 potentially impacted) with two cycles of exposure will be discharged due ,
l to symmetry concerns with the reload. Replacing these four fuel assemblies will result in a small decrease in the upcoming cycle length.
The dropped fuel bundle will be returned to General Electric. General Electric has provided a new fuel bundle for use for the upcoming cycle.
1 Since a piece of an LPRM was found in the fuel rack and it could not be determined l how it came to rest there, an inspection of the Unit One fuel rack will be l performed with a camera. This inspection will check for the possibility of other
! obstructions and will cover any open locations and locations where an assembly is not fully seated (NTS 2542008908002). Also, a review of LPRM disposal (cutting and transfers) will be completed to determine any actions that could be taken to prevent this situation from occurring again (NTS 2542008908004).
F. PREVIOUS EVENTS:
I A review of past Licensee Event Reports and Deviation Reports revealed one instance of a dropped fuel assembly. This event is documented in D-4-1-80-52 ano concerns a l new fuel assembly which was dropped while being lowered into the fuel pool using
! the overhead crane to place it in a fuel rack. The assembly fell on an empty portion of the fuel rack. Corrective action for the event included requiring that L
i new fuel movements within the fuel pools be performed with the refuel bridge.
1 G. COMPONENT FAILURE DATA:
There was no component failure identified in this event.
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