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 Report dateSiteEvent description
05000483/LER-1984-011, Forwards LER 84-011-00 Re Unauthorized Operation of Plant Equipment.Ler Withheld (Ref 10CFR73.21)Callaway
05000483/LER-1984-056, Forwards LER 84-056-00Callaway
05000483/LER-1985-025, Forwards LER 85-025-01 Re Intermediate Range High Flux Reactor Trip Caused by Blown Fuse in ex-core Neutron Monitoring Channel.Expected Submission Date of Supplemental Rept Amended Due to Continuing InvestigationCallaway
05000483/LER-1986-038, Forwards LER 86-038-00 Re Containment Purge Isolation Signal & Control Room Ventilation Isolation Due to Increased Gaseous Radioactivity Levels in ContainmentCallaway
05000483/LER-1987-013, Discusses Encl LER 87-013-01 Re Inoperable Control Room Emergency Ventilation Sys.Ler Discusses Two Events When Both Trains of Sys Simultaneously Rendered Inoperable.First Event Caused by Personnel ErrorCallaway
05000483/LER-1990-006Callaway
05000483/LER-1990-008Callaway
05000483/LER-1991-001, Proposed Tech Specs,Revising Tables 4.3-1 & 4.3-2 to Address Compliance Problem Raised in LER-91-001-00,dtd 910401 Re OT Delta-T & OP Delta-T Channel Calibrs at Beginning of Each Cycle During Startup TestingCallaway
05000483/LER-1995-002, Forwards LER 95-002 Re Missed Surveillance of Containment Purge Exhaust Sampling Valve Circuit Feed Breaker & Inoperable Fuse Due to Personnel OversightCallaway
05000483/LER-1995-003, Forwards LER 95-003 Concerning Missed Surveillance of Refuel Water Storage Tank Protection Loop BNLP0933Callaway
05000483/LER-1997-005, Forwards LER 97-005-05,re Situation in Which Surveillances Required by TS Were Missed Due to Misintepretation of SR, Per 10CFR50.73(a)(2)(i)(B)Callaway
05000483/LER-1998-001, Forwards LER 98-001-01,being Submitted to Clarify Scope of Original Reviews Performed for Corrective Action Number 3 in LER 98-001-00.Reviews Have Identified Case of Failure to Properly Establish Equipment OperabilityCallaway
05000483/LER-1998-003, Forwards LER 98-003-01 Re Inadvertent Actuation of ESFAS Due to 'A' SG High Level During Refuel 9.Rept Is Submitted to Report Change in C/A from That Reported in Original ReptCallaway
05000483/LER-1998-008, Forwards Amended Response to GL 81-07, Control of Heavy Loads, to Address Corrective Action Described in LER 98-008-00.Discrepancy Between Earlier Submittals of Snupps Rept on Control of Heavy Loads & TS Re RHR Sys,ResolvedCallaway
05000483/LER-2002-00412 April 2002Callaway

On 2/13/02, Callaway Plant was in Mode 4 with Reactor Coolant System (RCS) temperature at 300 degrees F and RCS pressure at approximately 395 psig. The Reactor Trip Breakers were closed, Main Turbine Shell warming was in progress, and Auxiliary Feedwater system testing was being conducted. At 0434, a Reactor Protection System (RPS) signal was generated that tripped open the Reactor Trip Breakers. Subsequent investigation revealed the trip was due to pressure in the Main Turbine increasing above an interlock setpoint of 56 psig (P-13), which is equivalent to 10 percent power. When this interlock was satisfied, it in turn enabled a Low Pressurizer Pressure Reactor Trip permissive (P-7) with a setpoint of RCS pressure less than 1885 psig. Since RCS pressure was approximately 395 psig, an RPS signal was generated to open the Reactor Trip Breakers.

The cause of the event was operating procedures not clearly identifying plant conditions required to perform Main Turbine Shell Warming. Corrective actions taken were to revise plant procedures to reflect appropriate cautions and restrictions for performing Main Turbine Shell warming.

05000483/LER-2002-00512 April 2002CallawayOn 2/18/02, Callaway Plant received Westinghouse Letter SCP-02-14, which transmitted Nuclear Safety Advisory Letter (NSAL) 02-03. This NSAL addressed an error in the Westinghouse Steam Generator (S/G) water level setpoint analysis in which the pressure drop across a mid-deck plate internal to the S/G separator assembly was not accounted for in analysis calculations. This pressure drop adversely affected S/G low-low setpoint uncertainty calculations. On 2/28/02, Callaway staff engineers determined that this situation was applicable to Callaway with the S/G low-low setpoints being nonconservative and that the S/G Low-Low Trip function might not provide protection against a Main Feed Line Break (MFLB) inside Containment. A decision was made to reduce reactor power to approximately 30 percent and adjust the S/G Low-Low Trip setpoints to 21.6 percent narrow range level for normal containment environment and 27 percent narrow range level for adverse containment environment, which would satisfy the safety analysis requirements. Additional corrective actions included revision of plant procedures utilizing the S/G Low-Low Trip values.
05000483/LER-2002-008Callaway

On 4/18/2002, during an extent of condition review concerning the neutron flux positive rate trip function, a concern was identified where Technical Specification (T/S) Table 3.3.2-1, Allowable Value for the Steam Line Pressure Negative Rate - High (HNPR), is less restrictive than the Safety Analyses Limit (SAL) credited in the Callaway Mode 3 Main Steam Line Break (MSLB) analysis.

T/S lists the allowable value for the HNPR function as less than or equal to 124 psi. T/S Bases lists the Nominal Trip Setpoint (NTS) for the HNPR function as less than or equal to 100 psi. The Safety Analysis Limit (SAL) for the HNPR function is 100 psi.

Consequently, the current T/S allows the HNPR function to be set at a value less conservative than the value assumed in the safety analysis.

Corrective actions being evaluated include either decreasing the T/S Allowable Value from less than or equal to 124 psi to less than or equal to 100 psi, or revising the Callaway Mode 3 MSLB analysis to credit a HNPR SAL greater than or equal to 124 psi.

Because the plant was operating in Mode 1, there were no immediate operability concerns. A Generic Letter 91-18 Operability Determination was completed which included the required compensatory actions for T/S compliance if the plant is taken to Mode 3 with reactor coolant system pressure below the P-I I setpoint of 1970 psig.

05000483/LER-2002-010Callaway

On 6/25/02, with Callaway Plant in Mode 1 at 100 percent power, testing was being conducted involving "A" Train Ultimate Heat Sink (UHS) sump heater, SEFO2A. When energized, the motor control center (MCC) feeder breaker, NG0705, tripped.

Investigation revealed that SEFO2A was grounded and that its feeder breaker protection was not properly coordinated with the MCC feeder breaker. The next closest breaker with ground fault protection was NG0705.

An extent of condition review was completed that revealed a potential for safety related components and load centers to experience a common cause failure if a single fire were to occur in Auxiliary Building Fire Area A-1. MCC's NGO I A and NGO2A could experience a fire induced ground fault condition due to cable damage on downstream loads, which could cause the loss of either, or both, NGO1A and NGO2A.

In addition, cables in Fire Area A-1 for "A" and "B" Residual Heat Removal pump room coolers have less than the required 20 feet of horizontal separation per FSAR Table 9.5E-1.

Compensatory actions taken include establishment of hourly firewatches in affected areas, isolation of circuit breakers for UHS sump heaters pending completion of an electrical design change, issuing an Operations Night Order detailing actions to be taken to restore NGO1A and/or NGO2A in the event of a fire, and evaluating revisions to Fire Area Pre-plans.

05000483/LER-2002-011Callaway

At 1419 CST, 11/5/02, in Event Notification # 39345, Callaway reported the following:

"During refueling outage RF12, interim results of "A" Steam Generator tube inspections indicate 62 tubes out of 5431 tubes (i.e., > 1%) have been found to be defective. This steam generator tube inspection result for the "A" Steam Generator is classified as category C-3 in accordance with Technical Specification 5.5.9, Table 5.5.9-2. All defective tubes will be plugged before the steam generator is returned to service. There were no adverse safety consequences or implications as a result of this event. This event did not adversely affect the safe operation of the plant or the health and safety of the public. " This initial notification was reported under 10CFR50.72(b)(3)(ii)(A) as a Degraded Condition, however, under NUREG 1022, section 3.2.4, discussion (A) 3, the present C-3 classification of the "A" Steam Generator (S/G) tubes does not meet the listed criteria for serious S/G tube degradation. The initial notification was amended to reflect that the report was made per requirements of Technical Specification (T/S) 5.5.9, Table 5.5.9-2 only. The C-3 condition does not meet the criteria for serious S/G tube degradation and is not a degraded or unanalyzed condition. This LER is submitted in compliance with T/S requirements, not due to an actual serious S/G tube degradation.

05000483/LER-2003-001CallawayOn 01/07/03, with the Plant in Mode 1 at 100 percent Reactor Power, valve EGHVO061 (Component Cooling Water from Reactor Coolant Pump Thermal Barrier Outer Containment Isolation Valve) failed to stroke fully closed, during Containment Isolation Valve Inservice Testing. EGHVO061 was declared inoperable at 2012 and Technical Specification (TIS) 3.6.3.A.1 was entered. At 2020, EGHVO133 (the bypass valve for EGHVO061) was opened and then EGHVO061 valve was fully closed with power removed from the valve in order to satisfy T/S 3.6.3 A.1 for the EGHVO061 penetration flow path. The T/S required position for valve EGHVO133 is closed with power removed, except when opened under administrative controls. Later it was determined that EGHVO133 and EGHVO062 (the inner containment isolation valve) were both powered from Bus NGO2B. This discovery revealed that the administrative controls were inadequate. This was a condition prohibited by the Plant's T/S. This condition existed until 01/10/03 when EGHVO061 was returned to service. The root cause of the event was a failure to recognize the common power source for both valves. Corrective actions included revising the test procedure to establish the requirement for local operation of these valves when administrative , controls are required.
05000483/LER-2003-0025 May 2003Callaway

At 0148, 3/5/03, EGHVO061 was declared inoperable due to failing to stroke full closed during containment integrity surveillance, 5704626. Technical Specification (T/S) 3.6.3 was entered and EOSL 10582 was written to track T/S time limits.

EGHVO061 is a parallel sliding gate valve. Investigation revealed the valve failed to stroke to the full close position due to a hydraulic lock developing between the two valve discs. This was a repeat of a problem on 1/8/03. Actions taken in January involved valve disassembly and removal of a viscous film discovered on all areas where a no flow or low flow condition existed.

Post maintenance testing indicated that cleaning resolved the problem. This was supported by testing performed under 5539676 on 2/5/03.

Upon the second failure of EGHVO061, further investigations were conducted. Manufacturer Velan Valve Corporation recommended drilling a 0.25-inch hole in the upstream disc to relieve any pressure trapped between the discs. This modification was performed and testing demonstrated proper operation and stroke times. At 1418, 3/7/03, EGHVO061 was declared operable. This failure was caused by changing valve stroke length in RF12. The actual inoperable time span was from the last valve stroke in RF12 at 2116, 11/17/02, until proper restoration was completed at 1418, 3/7/03 for a total time span of 109 days, 17 hours, 2 minutes.

05000483/LER-2003-003Callaway

On 3/13/03 while at 100 % power, during a review of future plant modification packages, Callaway Plant determined a problem existed in the current safety analysis for a steam generator tube rupture (SGTR) accident accompanied by an overfill condition. The current Final Safety Analysis Report (FSAR) does not explicitly address a SGTR overfill case. Investigations determined that for current plant conditions, an overfill condition could result if an auxiliary feedwater control valve supplying the ruptured steam generator (S/G) were to fail open. In this case water could be released through the S/G safety valves, resulting in a radioactive release to the environment greater than allowed by regulatory guidance. Since the SGTR overfill case was not explicitly addressed in the FSAR, credited operator action times were not maintained current.

To assure regulatory compliance, plant procedures have been changed to administratively reduce the steady state Dose Equivalent Iodine (DEI) limit to 0.3 microcurie per gram (Technical Specifications currently limits DEI to 1.0 microcurie per gram). This lower DEI limit will ensure that if a SGTR overfill condition were to occur, post accident radiological consequences would not exceed limits contained in the FSAR and Standard Review Plan.

05000483/LER-2003-0049 June 2003Callaway

On 4/11/03, while at 100 percent power, it was discovered that a note contained in Technical Specification (T/S) 3.3.9 for the Boron Dilution Mitigation System (BDMS), had been inappropriately applied during past reactor startups. This had been interpreted to allow blocking BDMS while withdrawing Shutdown (S/D) Bank rods in Mode 3. This action is not allowed in Mode 3 per Final Safety Analysis Report (FSAR) accident analysis Section 15.4.6.2 where BDMS is credited for automatically terminating a dilution event while in Mode 3.

Wording of T/S 3.3.9 and T/S 3.3.9 Bases did not provide clear guidance as to what constitutes "reactor startup". The Bases indicate BDMS could be blocked prior to withdrawing "rods" for startup. These words do not delineate between control banks and shutdown banks. Based on this unclear guidance, procedure OTG-ZZ-0001A was incorrectly revised allowing the blocking of BDMS prior to withdrawing shutdown banks. The discovery of the unclear T/S wording was the result of requested procedure enhancements to clarify when it was allowable to block BDMS.

A review of reactor startups within the last 3 years indicated that BDMS was inappropriately blocked on three separate startups.

The first occurred on 11/24/02, the second on 12/17/02, and the third on 4/2/03. Plant procedures governing reactor startup were revised to remove statements allowing blocking BDMS while withdrawing S/D Bank rods in Mode 3.

05000483/LER-2003-00521 July 2003Callaway

On 5/22/03, with Callaway Plant in Mode 1 at 100 percent power, surveillance testing was being performed involving "B" Containment Spray pump, PENO1B. Upon starting, the pump failed to develop normal discharge pressure and flow for approximately 5 minutes. The pump then developed pressure and the test was completed satisfactorily. Subsequent review determined the pump had been gas bound. Ultrasonic exams and dynamic venting demonstrated that PENO1B was water solid and operable. An extent of condition review revealed that Containment Spray pump, PENO IA had experienced a 2 minute gas binding event on 4/29/03. Ultrasonic exams and venting were conducted and verified that PENO IA was operable. It was determined that both pumps were gas bound due to an inadequate system venting configuration after Mode 5 valve testing on 3/30/03 resulting in both trains of Containment Spray being inoperable upon entering Mode 4 on 3/31/03 until PENO IA was run on 4/29/03, and "A" train was declared operable. This resulted in noncompliance with Technical Specification 3.6.6 for a period of time greater than allowed. Potential corrective actions being evaluated include installing additional vent valves, and procedure improvements to address dynamic venting.

05000483/LER-2003-00618 March 2004Callaway

This revision of LER 2003-006-00 is being submitted to change the reporting criteria to specify that this is only a voluntary LER and no violation occurred. On 7/3/03, with Callaway Plant operating in Mode 1 at 100 percent power, and during development of Licensed Operator Continuing Training (LOCT), it was discovered that an error existed in emergency procedure E-3, STEAM GENERATOR TUBE RUPTURE. The postulated accident involved a reactor trip due to a loss of off-site power compounded by a steam generator tube rupture (SGTR) on "D" loop of the reactor coolant system, and a stuck open auxiliary feedwater flow control valve. Early in the procedure, the Pressurizer Power Operated Relief Valves (PORV) were being armed in order to provide cold overpressure protection during the cool down phase. By arming the PORVs early, this made it difficult to meet the conditions required to secure Safety Injection later in the SGTR recovery, which potentially could prolong recovery from the SGTR. Prolonged recovery would result in additional liquid being released to the atmosphere via the ruptured steam generator's atmospheric dump valve and additional dose to the public.

Once the procedure error was identified, a procedure revision was issued which corrected the problem.

05000483/LER-2003-007Callaway

This revision of LER 2003-007-00 is being submitted to delete the reporting criteria for an event or condition that could have prevented fulfillment of a safety function. Other previously identified reporting criteria remain applicable.

On 7/17/03, with Callaway Plant at 100 percent power, an error was found in Engineering Evaluations that approved having the Health Physics (HP) Access doors 32201 and Hot Lab door 32282 open. These doors are pressure boundary doors between the Control Building and Communication Corridor and are required to be closed during accident conditions. With the doors open, HP Access Control fan coil unit SGKO3 would cause air from outside the Control Building to enter the HP Access area and mix with Control Building atmosphere. The Control Building atmosphere is credited in post-accident Control Room radiological consequence analysis and an outside air source has potential for impacting dose received by Control Room staff. An evaluation determined 25 minutes to close these doors in an emergency, which could result in an exposure of approximately 31.5 REM to Control Room staff. This dose was above regulatory limits and the event was classified as reportable as an unanalyzed event and a violation of Technical Specifications. When the door issue was identified, the doors were closed and a plant bulletin was issued indicating the doors were to remain closed except during normal use. Although the Regulatory Guide 1.195 dose limit and ICRP 30 Dose Conversion Factors are not currently part of Callaway's Licensing bases, they do demonstrate the limited safety implications of this event.

05000483/LER-2003-008Callaway

On 9/4/03 with Callaway in Made 1 at 100 percent power, a modification to replace the handswitch for "IT Pressurizer (Pzr) Power Operated Relief Valve Block valve (BBHV8000B) was implemented. During post modification testing, the valve operator and control breaker were damaged. The modification required removal of a wire which had not been specified by the modification work instructions. Repairs were performed and the valve control circuitry was restored to pre-modification conditions. The reportable condition occurred 9/7/03 when the Technical Specification Required Actions were not met within the associated Completion Time. interim corrective actions restrict planning of motor operated valve control circuit work documents. Long term corrective actions include strengthening the training and qualification process for the planning of motor operated valve modification work documents.

NRC FORM W6(7-2001) DOCKET (2) LER NUMBER (6) Callaway Plant Unit 'I FACILITY NAME (1)

05000483/LER-2003-009Callaway

At 0721, 10/20/03, with Callaway Plant at 100 percent power, inverter NN11 failed causing a momentary loss of electrical power to safety related AC bus NN01.The Control Room staff used approved plant procedures to recover from the event and stabilize plant conditions. Subsequent repair investigations extended past the 24 hour Technical Specification (T/S) Action time limit and a TJS required plant shutdown was performed. It was determined that the NN11 failure was due to a faulted static transfer switch circuit board. Repairs were completed and NN11 was declared Operable at 2202, 10/21/03. A plant startup was performed on 10124/03 and normal plant operations resumed.

NRC FORM 360 (7-2001)

05000483/LER-2004-002Callaway

At 1830, 1/27/04, while at 100 percent power, Callaway Plant experienced a main electrical generator trip which in turn caused a reactor trip due to power being above 50 percent. The cause of the generator trip was a failed electrical relay.

This relay was designed to sense remote faults in order to prevent exceeding thermal limits for the stator windings. Plant systems responded as designed, including automatic actuation of the auxiliary feedwater system.

The faulted relay was repaired, calibrated, and reinstalled. This relay contained a second set of unused contacts which were used instead of the initial faulted contacts. This relay configuration was successfully retested and plant operation resumed without further problems.

A review of relevant operating experience did not identify similar failures, and a review of past plant preventative maintenance did not reveal abnormalities. Preventive maintenance procedures will be revised to provide additional detailed instructions for inspection of these relay contacts for this failure mechanism.

05000483/LER-2004-0032 April 2004Callaway

At 0439, 2/3/04, with Callaway Plant at 100 percent power, a reactor trip occurred while operating breakers in the site distribution switchyard. Plant operators responded to the event using plant procedures and stabilized the plant in Mode 3. All safety systems initially responded as required to the event. Investigations determined a faulted timer relay in the dead machine protection circuit for the main generator caused a trip of the main generator output breakers and subsequent reactor trip.

3 hours 17 minutes after the trip, the Turbine Driven Auxiliary Feedwater Pump (TDAFP) tripped. Extensive methodical investigation resulted in replacement of three components in the control system, and the TDAFP was declared operable.

Due to the complexity of the TDAFP investigation, an emergency one-time change to Technical Specification 3.7.5 was requested and approved.

The failed timer relay in the dead machine circuit, and the three suspect control system components were all replaced and both pieces of equipment were returned to service.

05000483/LER-2004-0049 April 2004Callaway

At 2258, 2/11/04, with the plant in Mode 3, a Safety Injection (SI) occurred while performing a plant heat up to normal reactor coolant system operating pressure and temperature. The SI was the result of not performing a step contained in the procedure governing a plant heat up. All safety systems actuated as required and flow was initiated to the core due to plant conditions present at the start of the event. Emergency procedures were used to terminate the event and restore the plant to a normal condition. During the event, "B" Steam Generator Auxiliary Steam Dump (S/G ASD) did not properly operate and "A" Reactor Coolant Pump (RCP) exhibited high vibration. The "B" S/G ASD problem was identified as an obstruction of a balance arm within an electropneumatic transducer which was corrected and tested to verify operability. The RCP vibration was determined to be the result of thermal transients caused by the SI and did not require additional action.

A Root Cause Analysis investigation was conducted which revealed inadequate pre-job briefs, weaknesses in supervisory oversight, and cumbersome operating procedures as root causes for this event.

05000483/LER-2004-0059 April 2004Callaway

On 2/15/04, during plant startup and synchronizing to the grid, Callaway experienced oscillations in Steam Generator (S/G) levels which resulted in a main turbine generator trip and subsequent reactor trip. After the reactor trip occurred, to reduce the plant cooldown rate, operators attempted to secure the Turbine Driven Auxiliary Feedwater Pump (TDAFP). However, due to an automatic actuation signal being present, the TDAFP experienced an electrical and mechanical overspeed trip.

Post trip investigations determined that the S/G oscillations were due to not having aligned extraction steam to provide feedwater preheating. The overspeed trip of the TDAFP was per system design. A TDAFP actuation signal was present when the operators closed the steam supply valves, causing the valves to reopen automatically and in such a sequence as to cause an overspeed condition.

A Root Cause Analysis team was assembled and identified four Root Causes, plus several Corrective Actions to Prevent Occurrence.

05000483/LER-2005-002Callaway

At 0300, 3/23/05, 72-hour Technical Specification Action 3.7.8.A was entered when a pinhole leak was discovered in "B" Essential Service Water (ESW) system between the "B" ESW pump strainer and discharge isolation valve. Subsequent ultrasonic testing (UT) determined that approximately seven linear feet of piping in the "B" ESW train was affected and required replacement. UT testing was satisfactorily performed on the identical section of "A" ESW train to ensure a similar problem did not exist.

"B" ESW train piping replacement was performed in accordance with planned work documents, however at 2100, 3/25/05 all necessary repairs and retests had not been completed. Although only 66 hours had expired since entering 72-hour Technical Specification Action 3.7.8.A, Callaway Plant proactively decided to commence a reactor plant shutdown in accordance with Technical Specification Action 3.7.8.B for an Inoperable "B" Essential Service Water train.

At 0624, 3/26/05 the reactor was declared shutdown and Callaway Plant entered Mode 3. At 0249, 3127/05 all repairs and retests were completed on the "B" ESW train and it was declared Operable. Instead of beginning a return to operation, plant management decided to perform additional discretionary work to enhance unit reliability and as a result, Callaway did not return to power until 1907, 4/2/05.

05000483/LER-2005-003CallawayOn 3/29/05 while in Mode 3, preparations were underway to perform a leak test of "C" Steam Generator (S/G) Main Feedwater Isolation Valve AEFV0041. While establishing necessary initial conditions, S/G level oscillations began to occur. As part of the leak test, main feedwater flow was isolated to the "C" S/G. Due to a low differential between the discharge pressure of the condensate pump being used to maintain S/G levels and main steam header pressure, leakage past AEFV0041 sustained "C" S/G level until the "C" S/G Bypass Feedwater Regulating Valve was manually isolated. This isolation of flow to "C" S/G resulted in level decreasing until a low level alarm actuated. After initiating auxiliary feedwater flow, level initially increased but subsequently began decreasing until a reactor trip occurred due to low-low water level in "C" S/G. Plant systems responded as required and all systems were stabilized at normal Mode 3 conditions. A Root Cause Analysis team concluded that this event occurred because the general operating procedure and the leak test procedure were deficient and on-shift operators decided not to utilize a start-up feed pump verses the condensate pump. Corrective actions included revising the test procedure and covering this event in future licensed operator training.
05000483/LER-2006-00410 August 2006Callaway

On 5/12/2006 reactor power was being reduced to 45% for a planned maintenance activity. Reactor power had been lowered to approximately 48% when vibration on main turbine bearings started rising eventually reaching the turbine trip criteria. The turbine was manually tripped at 0047 on 5/12/2006.

Control rods subsequently stepped in under automatic rod control, as designed. The control rods I continually stepped in reducing power below 10% in approximately four minutes. Feedwater flow was controlled through the Main Feedwater Regulating Valves which are not normally in service below 20% power. At 0052, the Steam Generator High-High Level setpoint was exceeded on the 'A' Steam Generator resulting in a Feedwater Isolation Signal and Motor Driven Auxiliary Feedwater Actuation Signal. All safety systems responded as designed. A manual reactor trip was initiated at 0053 in accordance with procedural guidance for the loss of both main feedwater pumps. The cause of this event is an inadequate mitigation strategy in procedure OTO-AC-00001, "Turbine Trip below P-9" (50% power permissive setpoint). The procedural deficiency was the result of an inadequate procedure change review� I process used in 1991. Corrective Actions to Prevent Recurrence include revision of the procedure change review process and revision of OTO-AC-00001 to incorporate an appropriate mitigation strategy.

05000483/LER-2006-00926 January 2007CallawayPrior to June 2006 Callaway Plant Technical Specification 3.7.2 did not explicitly address Main Steam Isolation Valve actuator trains. Inoperability of actuator trains was addressed through a Technical Specification Interpretation, which specified that due to the redundant actuator design, inoperability of a single actuator train did not render the associated isolation valve inoperable. The interpretation was eventually incorporated into Chapter 16 of the Final Safety Analysis Report and applied to the failure of a single actuator train on December 29, 2004. The NRC questioned the use of this provision and took the position that Main Steam Isolation Valve Technical Specification 3.7.2 requirements should have been imposed. The issue was identified as an Unresolved Item for which NRC Office of Nuclear Reactor Regulation involvement was required. Prior to NRC resolution, Callaway Plant determined that Technical Specification 3.7.2 was inadequate. In May 2005, a license amendment request was submitted to explicitly include requirements for the actuator trains under Technical Specification 3.7.2. The NRC approved and issued the amendment request in June 2006. Following issuance of the license amendment, the ongoing NRC evaluation reached resolution in October 2006. The NRC concluded that the requirements of Technical Specification 3.7.2 were inadequately applied prior to the license amendment and should have been imposed for past instances of actuator train inoperability.
05000483/LER-2007-00330 August 2007Callaway

During calibration of Reactor Coolant System (RCS) Temperature Loop 3 on June 30, 2007, problems were identified which called into question the validity of a previous calibration on Loop 2. On June 30/July 1, 2007, Reactor Coolant System (RCS) Temperature Loop 2 calibration surveillance was performed to verify the results from the last loop calibration performed on June 9, 2007. It was determined that the Lower Flux input to the Over Temperature Delta Temperature (OTDT) setpoint circuit was Out of Tolerance (OOT). This condition was determined to have been sufficient to cause the OTDT setpoint to exceed its Technical Specification Allowable Value. The Loop 2 OTDT setpoint was inoperable for 21 days. The Temperature Loop 2 setpoint was returned to the correct value on July 1, 2007.

When RCS Temperature Loop 2 was calibrated on June 9, 2007 a wrong test configuration was used when making connections to simulate the Lower Flux input to the flux imbalance penalty circuitry in the Westinghouse 7300 system. The negative power supply lead must be grounded to properly simulate the input from the Nuclear Instrumentation System (NIS) cabinets; during the June 9, 2007 calibration this was not established. The calibration was performed on July 1, 2007 using the proper configuration. The loop calibration procedures have been revised to ensure the basis for this ground connection is clear.

05000483/LER-2008-004Callaway

At 2331 on October 17, 2008, while the Refuel 16 refueling outage was ongoing, core off-load recommenced with the equipment hatch open and the containment purge and exhaust system not in service. The mini-purge exhaust fan was then started at 0212 on October 18, 2008. Core alterations continued from 2331 on October 17, 2008 to 0212 October 18, 2008 (2 hours, 41 minutes) with the equipment hatch open and the containment purge and exhaust system not in service. On October 19, 2008 Operations, when planning restoration of the load center associated with the containment shutdown purge exhaust fan, determined that this was in violation of Callaway operating procedure OSP-SF-00003 (Rev. 018) step 6.3.4 and Technical Specification (T/S) 3.9.4.

A root cause investigation was performed to determine causes and corrective actions for the resulting condition prohibited by T/S. The investigation found that the root cause of the failure to have the containment purge and exhaust system in service during core alterations with the equipment hatch open was a failure to adequately or completely implement Callaway Operating License Amendment 152 in procedures. The corrective action to prevent recurrence (CATPR) was to update Operations procedures to address administrative controls for having the equipment hatch open. This CATPR is complete.

05000483/LER-2008-00523 December 2008Callaway

On 11/11/2008, while operating at 97-percent reactor power, with power increasing following Refuel 16, the "B" main feedwater pump (MFP) turbine tripped. Since the loss of one MFP at greater than 80-percent power challenges the plant's ability to maintain steam generator (SG) water levels to support continued plant operations, the reactor was manually tripped per plant operating procedures.

All control rods fully inserted during the event and all safety systems responded as designed. Operation of the Auxiliary Feedwater system restored SG levels. Operation of the main steam supply system provided the heat sink for decay heat removal following shutdown. No primary relief valves or main steam relief valves lifted during the event. No primary to secondary leakage existed. No radioactive material was released. This event was considered an uncomplicated reactor trip.

The cause was that the o-rings in the MFP lube.oil strainer were a material susceptible to swelling in petroleum- based lubrication systems. An o-ring originally located in one of the MFP lube oil basket strainers swelled, became dislodged, and traveled into a MFP turbine bearing oil supply pressure regulating valve. The corrective actions to prevent recurrence included identification of a replacement for the o-rings. The correct o-rings were installed in both strainers for the "A" and "B" MFP turbine oil system.

05000483/LER-2008-0076 February 2009Callaway

At 1042 on 12/12/2008, while in Mode 3, an invalid reactor trip signal was generated during maintenance activities on intermediate range (IR) nuclear instrument SEN0036. In addition to the reactor trip, a feedwater isolation actuation occurred. Reactor Operators manually started motor driven auxiliary feedwater pumps to maintain steam generator levels, prior to an anticipated Auxiliary Feedwater actuation.

The IR high flux reactor trip was a result of removal of the control power fuses for IR nuclear instrumentation N-36 while performing work to replace a bistable card for SEN0036. It was desired to de-energize equipment prior to circuit card replacement to protect electronic circuits. When a step was included in the work document to remove the control power fuses it was not understood that a relay would be de-energized which allowed the IR High Flux Reactor trip signal to be generated.

Corrective action (CA) will include installing labels and training instrumentation and controls personnel about the effects of pulling control power fuses for nuclear instrumentation.

05000483/LER-2010-00220 April 2010Callaway

On 2/19/10, upon review of industry operating experience, Callaway Plant identified a condition in which the actuation logic for anticipatory start of the Motor-Driven Auxiliary Feedwater (AFW) pumps upon trip of both Main Feedwater (MFW) pumps would not be satisfied as required by Table 3.3.2-1 Function 6.g of the Technical Specifications (TS).

This condition exists when one MFW pump (MFP) is operating and the second MFP in secured in a 'Reset' configuration.

Low pressure on the MFP Turbine Trip Oil Header is used to indicate a MFP trip. However, the Trip Oil Header is also used to keep the 'Reset' MFP turbine stop valves open such that the Trip Oil Header pressure of a 'Reset' MFP is the same as an operating MFP that is providing flow to the steam generators. As a result, all MFW flow would be lost upon the trip of the operating MFP, but the actuation logic for anticipatory start of AFW upon trip of both MFPs would not be satisfied.

The cause of this event has been identified as a lack of detailed design basis information regarding this function.

Corrective actions include TS to allow both channels associated with a 'Reset' MFP turbine to be placed in a tripped condition (enabling the AFW actuation logic to be satisfied as required upon trip of the operating MFP) and the addition of information related to this function into licensing documents and procedures.

05000483/LER-2010-00430 April 2010Callaway

On March 2, 2010 with the plant in MODE 1 at 100% reactor power, a latent design issue was identified in regard to the essential service water (ESW) system and ultimate heat sink (UHS). Upon review of a calculation for UHS performance, it was determined that a limiting single failure had not been evaluated. During a Loss of Coolant Accident (LOCA), both ESW trains are assumed to operate for the first 8 hours of the accident. If a UHS bypass valve were to fail during a LOCA, flow from one train of ESW would be cooled by the UHS cooling tower while flow from the other train of ESW would flow directly to the UHS pond. This would lead to the UHS pond temperature increasing more quickly than previously analyzed, potentially exceeding the UHS pond temperature design basis accident limit in as little as an hour with no operator actions.

The cause for this unanalyzed condition is failure to re-evaluate the UHS/ESW single-failure analysis when UHS cooling tower capacity was questioned during construction of the plant. For corrective action, emergency operating procedures will be revised to include operator action if UHS bypass valves are lost during an accident scenario.

Design procedures are being updated to minimize the probability of generating non-conservative specifications, using non-conservative design inputs and assumptions in a calculation, and not evaluating single active failure in plant modifications as the corrective action to prevent recurrence.

05000483/LER-2013-00115 February 2013Callaway

On 14:35 on 12/17/2012, the A Class lE electrical equipment air conditioning unit (SGKO5A) was declared inoperable due to identification of Freon leakage from the unit's low oil pressure and compressor discharge sensing lines. Following repair to address the leakage, the unit was declared operable at 11:08 on 12/18/2012.

The SGKO5A unit provides a support function for the A train of Class lE electrical equipment. The Class lE electrical equipment is addressed in the plant's Technical Specifications. Since the leakage for SGKO5A had apparently existed prior to the time of discovery, it was concluded that SGKO5A and the supported Class 1E electrical equipment had been inoperable for a period of time longer than the allowed by the plant Technical Specifications.

The leakage was the result of two sensing lines rubbing together. The Root Cause was determined to be an inadequate scope of previously conducted equipment reliability evaluations on the HVAC system. The leaks were repaired. In addition, preventive maintenance and monitoring of vibration-susceptible Class lE electrical equipment air-conditioners will be increased.

05000483/LER-2013-00217 June 2013Callaway

On 2/13/2013, during surveillance testing of the 'B' Train of the ESW system, an Operations Technician noticed that the oil in the sight glass of the lower motor radial bearing appeared darker than normal. Based on analysis of the oil, the 'IV ESW pump was declared inoperable on 2/14/2013 at 0721. Required Action A.1 of TS 3.7.8 was entered. Following replacement of the pump motor due to evidence of a degraded bearing, the 'W ESW train was restored to operable status at 1345 on 2/16/2013 such that Required Action A.1 was exited after a period of 54 hours and 24 minutes. Based on a conservative evaluation of past operability, it is estimated that the 'B' ESW pump motor would not have been capable of meeting its Operability mission time of 30 days after the August to October 2012 timeframe; therefore, this condition is currently considered reportable. This determination is based on the presence of metallic contaminants found in the oil and on recently increased motor vibration, which are indicative of bearing degradation.

The direct cause is insufficient motor shaft endplay, resulting in lower bearing failure due to excessive axial loading.

Corrective actions include establishing new preventive maintenance overhaul requirements and establishing new motor shaft endplay settings.

NRC FORM 356 (10-2010)

05000483/LER-2013-003Callaway

On 3/23/2013, the filtration fan associated with train 'B' of the Control Room Emergency Ventilation System (CREVS) tripped on thermal overload during restoration from surveillance testing. This occurred approximately 22 minutes after the fan was started. Based on this trip, the CREVS 'B' train was declared inoperable on 3/23/2013 at 2243. Required Action A of TS 3.7.10 was entered, and following replacement of the motor starter, the CREVS 'B' train was restored to operable status on 3/26/2013 at 0659.

Due to evidence of a loose connection and arcing at the termination for the 'C' phase of the filtration fan's starter, it was determined from this as-found condition that the CREVS 'B' train would not have been capable of meeting its Operability mission time of 30 days after 2/11/2013; therefore, this condition is considered reportable. This determination is based on the conclusion that the connection loosened slowly over time. A successful run of the fan on 2/11/2013 (without tripping) indicates that as of 2/11/2013, the connection had not loosened sufficiently to trip the fan on thermal overload.

The most probable cause of failure is tripping on thermal overload, due to a high resistance connection on the fan's starter.

Preliminary corrective actions include periodically checking the tightness of termination screws and inspecting for signs of overheating, for similar starters.

05000483/LER-2013-00417 June 2013Callaway

On 04/1 8/2013, a small fire occurred at the Unit Auxiliary Transformer which caused a loss of all non-vital power to the plant during core offload. At this point in the core offload, a fuel assembly was suspended in the spent fuel pool due to a torn grid strap. The assembly was considered to be in movement since the assembly was not in a "safe" or approved storage location. As a result of the loss of power, it was desired to restore temporary power to the 'B' train battery chargers to prevent loss (discharge) of the NK02 and/or NK04 batteries. Temporary power cables were routed through three doors in the Control Building, one of which was a Control Building Envelope (CBE) pressure boundary door. With cables running through the CBE door, mitigating actions were taken to seal the opening. Such mitigating actions are allowed in Modes 1-4 per Technical Specification (TS) 3.7.10, when Condition B applies for an inoperable CBE boundary. However, allowances for mitigating actions are not permitted for an inoperable boundary during the movement of irradiated fuel assemblies. For this situation, TS 3.7.10 Condition E applies, and its Required Actions are to immediately suspend CORE ALTERATIONS (E.l) and movement of irradiated fuel assemblies (E.2). The Control Room did not immediately recognize that Required Action E.2 was in effect; therefore, there was a delay in beginning this Action of approximately 2 hours and 24 minutes. Required Action E.2 was not met since the Action was not taken without delay.

NRC FORM 356 (10.20'0)

05000483/LER-2013-0053 June 2013Callaway

On 4/4/2013, during leak testing of a Service Water to Essential Service Water cross-connect valve, leakage in excess of 10 gpm was identified. Actions to further quantify the leakage rate and determine the cause of leakage found that the motor-operated valve (MOV) actuator coupling had become decoupled from the valve stem. Based on this finding, this valve was declared inoperable on 4/7/2013 at 20:46. Required actions B.1 and B.2 of Technical Specification 3.7.9 were entered. Repair of the valve was completed on 4/8/2013 at 0445.

After review of data from MOV testing on this valve, including a subsequent uncoupled test, it is estimated that the decoupled actuator condition could have existed for a significant period of time prior to discovery, possibly since 4/2/2012 when a leak check test performed on the valve identified zero leakage. Therefore, this condition is considered reportable.

The most probable cause is that bolts used to fasten the coupling block to the valve stem gradually loosened with the passage of time and from environmental effects, such as vibration and heating and cooling cycles.

Corrective actions include adding a periodic check of MOV valve shaft coupling block bolt torque to the periodic preventive maintenance performed on this and the other three cross-connect valves.

05000483/LER-2013-0063 July 2013Callaway

On May 8, 2013, during Refueling Outage 19, water was observed dripping from the insulation on piping connected to Reactor Coolant System (RCS) loop 4. Further investigation determined it was near a 3/4-inch ASME Code Class 2 line upstream of Safety Injection (EP) system valve EPV0109. The 3/4-inch vent line is located on the combined Safety Injection / Residual Heat Removal outlet piping which connects to the cold leg injection piping from Accumulator Tank D.

The RCS leakage identified at the noted location was indicative of degradation of a principal safety barrier and is considered reportable per the requirements of 10 CFR 50.73(a)(2)(ii)(A). Conditions that represent welding or material defects in the primary coolant system which cannot be found acceptable under ASME Section XI standards are reportable to this criterion.

The cracked vent line was removed and repaired on May 10, 2013. The completed weld repair was inspected and found acceptable.

An evaluation concluded that the leak was caused by induced cyclic fatigue crack at the socket weld upstream of valve EPV0109.

The safety significance of this event is low. The RCS leakage that resulted from the cracked vent line was well within the capability of the normal charging pump.

05000483/LER-2013-00723 July 2013Callaway

On 05/28/2013, oil was observed leaking from a 345-kV bushing on the Startup Transformer (XMR01) while the plant was in Mode 1. The leakage was addressed by tightening the bushing oil fill cap, and the Startup Transformer was declared operable on 05/30/2013 at 1648.

The Startup Transformer is part of one qualified preferred source of offsite AC power to the Class 1 E buses, as required by the plant's Technical Specifications. Investigation determined that the oil leak on the Startup Transformer was determined to have existed from a certain point in time prior to the time of discovery and that the Startup Transformer would not have been capable of meeting its Operability mission time of 30 days while the oil leak existed. Consequently, it was concluded that the transformer had been inoperable for a period of time longer than allowed by the plant's Technical Specifications.

The cause of this event was a human performance error which occurred during a maintenance activity on the Startup Transformer during Refueling Outage 19. Work instructions will be revised to provide photos and additional instruction on which components to loosen when power factor testing the Startup Transformer.

05000483/LER-2013-008Callaway

At approximately 2333 on July 26, 2013, electrical faults caused damage to the isophase bus to the unit auxiliary transformer and main generator neutral connection box. Protective relaying initiated a generator trip to isolate the faulted area and to trip the main turbine. A reactor trip from 100% power resulted from the turbine trip. A small cable insulation and oil collection pan fire initiated from the main generator neutral connection box fault and created smoke throughout the Turbine Building. An Unusual Event was declared as a result of the fire and resulting smoke.

The fire was extinguished within 30 minutes and smoke was removed from the building using installed equipment.

The electrical faults were the result of a damper blade that was loose within the isophase bus ductwork, creating arcing between the bus, damper blade, and duct. The loose damper blade is attributed to damper failure based on the determination that the operational isophase bus duct airflow rate exceeded the design flow rate for the backdraft dampers. Design and installation errors were made at the main generator neutral connection box during plant construction.

Redesigned backdraft dampers were installed, and grating was added to prevent debris from entering the isophase bus ducts. Modifications were also made to the generator neutral connection box.