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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17265A7541999-09-22022 September 1999 LER 99-011-00:on 990823,small Tears Were Discovered in Flexible Duct Work Connector at Inlet of CR HVAC Sys Return Air Fan (AKF08).Caused by in-leakage Greater than That Assumed.Implemented Temporary Mod 99-029.With 990922 Ltr ML17265A7431999-08-24024 August 1999 LER 99-004-01:on 990412,discovered That Containment Recirculation Fan Chevron Separator Vanes Were Installed Backwards.Caused by Improper Assembly by Mfg.Moisture Separator Vanes Were Dismantled & Correctly re-installed ML17265A7181999-07-23023 July 1999 LER 99-007-01:on 990423,reactor Trip Occurred Due to Instrument & Control Technicians Inadvertently Pulling Fuses from Wrong Nuclear Instrument Channel.Setpoint Adjustments Were Completed by Different Crew of Technicians ML17265A7081999-07-22022 July 1999 LER 98-003-02:on 980904,actuations of CR Emergency Air Treatment Sys Was Noted Due to Invalid Causes.Caused by Various Degraded Components in CR RM Sys.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored ML17265A7031999-07-19019 July 1999 LER 99-S01-00:on 990617,determined That Temporary Unescorted Access Had Been Granted to Contractor Employee.Caused by Incomplete Info Re Circumstances of Individual Military Separation.Individual Access Was Revoked.With 990719 Ltr ML17265A7021999-07-15015 July 1999 LER 99-010-00:on 990615,ventilation Isolation of Auxiliary Bldg Occurred When Auxiliary Bldg Gas Radiation Monitor R-14 Reached High Alarm Setpoint.Cr Operators Rest Auxiliary Bldg Ventilation Isolation Signal.With 990715 Ltr ML17265A6851999-06-21021 June 1999 LER 99-001-01:on 990222,deficiencies in NSSS Vendor steam- Line Brake Mass & Energy Release Analysis Results in Plant Being Outside Design Bases Occurred.Caused by Deficiencies in W.Temporary Administrative Replaced.With 990621 Ltr ML17265A6661999-06-0202 June 1999 LER 99-009-00:on 990503,instrumentation Declared Inoperable in Multiple Channels Resulted in Condition Prohibited by Ts. Caused by Unanticipated High Frequency AC Voltage Ripple. Entered TS LCO 3.0.3.With 990602 Ltr ML17309A6541999-05-27027 May 1999 LER 99-008-00:on 990427,overtemperature Delta T Reactor Trip Occurred Due to Faulted Bistable During Calibr of Redundant Channel.Plant Was Stabilized in Mode 3 & Faulted Bistable Was Subsequently Replaced.With 990527 Ltr ML17265A6631999-05-24024 May 1999 LER 99-007-00:on 990423,technicians Inadvertently Pulled Fuses from Wrong Nuclear Instrument Cahnnel,Causing Reactor Trip,Due to High Range Flux Trip.Caused by Personnel Error. Labeling Scheme Improved ML17265A6601999-05-21021 May 1999 LER 99-006-00:on 990421,start of turbine-driven Auxiliary Feedwater Pump Was Noted.Caused by MOV Being Left in Open Position.Closed Manual Isolation Valve to Secure Steam to Pump.With 990521 Ltr ML17265A6441999-05-13013 May 1999 LER 99-005-00:on 990413,undervoltage Signal of Safeguards Bus During Testing Resulted in Automatic Start of B Edg. Caused by Personnel Error.Blown Fuse Was Replaced & Offsite Power Was Restored to Safeguards Bus 17.With 990513 Ltr ML17265A6431999-05-12012 May 1999 LER 99-004-00:on 990412,discovered That Containment Recirculation Fan Moisture Separator Vanes Were Incorrectly Installed,Per 10CFR21.Caused by Improper Assembly by Mfg. Subject Vanes Were Dismantled & Correctly re-installed ML17265A6141999-03-31031 March 1999 LER 99-003-00:on 990301,two Main Steam non-return Check Valves Were Declared Inoperable Due to Exceedance of Acceptance Criteria.Caused by Changes in Methodology & Matls.Packing Gland Torque Will Be Adjusted.With 990331 Ltr ML17265A6131999-03-29029 March 1999 LER 99-002-00:on 990227,discovered That Surveillance Had Not Been Performed at Frequency,Per Ts.Caused by Personnel Error.Procedure O-6.13 Will Be Evaluated for Enhancement Documentation of Completion of ITS Srs.With 990329 Ltr ML17265A6061999-03-24024 March 1999 LER 99-001-00:on 990222,plant Was Noted Outside Design Basis.Caused by Deficiencies in NSSS Vendor Slb Mass & Energy Release.Placed Temporary Administrative Restriction 40 Degrees F Max on Screenhouse Bay Temp ML17265A4951998-12-21021 December 1998 LER 98-005-00:on 981120,loss of 34.5 Kv Offsite Power Circuit 751,resulted in Automatic Start of B Edg.Caused by Faulted Cable Splice.Performed Appropriate Actions of Abnormal Procedure AP-ELEC.1.With 981221 Ltr ML17265A4931998-12-17017 December 1998 LER 98-004-00:on 971030,determined That Improperly Performed Surveillance Resulted in Condition Prohibited by Ts.Caused by Procedure non-adherence.Appropriate Calibr Procedures Were Properly Performed with 24 H of Condition Discovery ML17265A4691998-11-25025 November 1998 LER 98-003-01:on 980904,actuations of CR Emergency Air Treatment Systems (Creats) Occurred.Caused by Radon build-up During Temp Inversion.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored to CR ML17265A4271998-10-0505 October 1998 LER 98-003-00:on 980904,actuations of CR Emergency Air Treatment Sys Occurred.Caused by Radon build-up During Temp Inversion.Air Samples Were Taken & Determined That Source of Radiation Was Naturally Occurring Radon.With 981005 Ltr ML17265A3671998-07-14014 July 1998 LER 98-002-00:on 971019,CR Emergency Air Treatment Sys Actuating Function Was Not Operable.Caused by Mispositioned Switch.Revised Procedure CPI-MON-R37.W/980714 Ltr ML17265A1921998-03-11011 March 1998 LER 98-001-00:on 980209,discovered That Boraflex Degradation in SPF Was Greater than Was Assumed.Caused by Dissolution of Boron on Boraflex Matrix,Per 10CFR50.21.Removed Spent Fuel Assemblies from Selected Degraded Storage Rack Cells ML17265A1641998-02-0606 February 1998 LER 97-007-01:on 971117,reactor Engineer Recognized That Neutron Flux Low Range Trip Circuitry for Channel Was Not in Tripped Condition as Required.Caused by Technical Inadequacies.Channel Defeat Will Be Identified ML17265A1601998-02-0606 February 1998 LER 97-006-01:on 971103,verification of B Concentration Was Not Performed Due to Misinterpretation of Event Sequence. Audible Count Rate Function Was Restored to Operable Status ML17264B1441997-12-17017 December 1997 LER 97-007-00:on 971117,NF Low Range Trip Circuitry for Channel N-44 Was Not Placed in Tripped Condition.Caused by Technical Inadequacies in Procedures.Implemented EWR 4862 to Resolve Design deficiency.W/971217 Ltr ML17264B1291997-12-0303 December 1997 LER 97-006-00:on 971103,NIS Audible Count Rate Function Was Inoperable.Caused by Misinterpretation of Event Sequence Due to Not Verifying Boron Concentration.B Verification Occurred Every 12 H Per ITS LCO Action 3.9.2.C.3.W/971203 Ltr ML17264B1271997-12-0101 December 1997 LER 97-005-00:on 971031,undetected Unblocking of SI Actuation Signal Occurred at Low Pressure Condition,Due to Faulty Bistable Which Resulted in Inadvertent SI Actuation Signal.Sias,Ci & CVI Signals Were Reset ML17264B1211997-11-24024 November 1997 LER 97-004-00:on 971024,radiation Monitor Alarm Were Noted Due to Higher than Normal Radioactive Gas Concentration Resulted in Cvi.New R-12 Alarm Setpoint Was Maintained for Duration of Refueling Outage ML17264B0461997-09-29029 September 1997 LER 97-003-01:on 970730,bistable Instrument Trip Setpoint Could Have Exceeded Allowable Value.Caused by Insufficient Existing Margin Between Trip Setpoint & Allowable Value. Held Switches in Tripped configuration.W/970929 Ltr ML17264B0111997-08-27027 August 1997 LER 97-003-00:on 970730,high Steam Flow Bistable Instrument Setpoint Plus Instrument Uncertainty Could Exceed Allowable Value in ITS Was Identified.Caused by Entry Into ITS LCO 3.0.3.Switches Placed in Tripped configuration.W/970827 Ltr ML17264A9941997-08-19019 August 1997 LER 97-002-00:on 970720,34.5 Kv Offsite Power Circuit 751 Was Lost.Caused by Automatic Actuation of B Emergency DG Due to Undervoltage on Safeguards Buses 16 & 17.Offsite Power Restored to Safeguards Buses 16 & 17.W/970819 Ltr ML17264A9911997-08-11011 August 1997 LER 96-009-02:on 960723,determined That Leak Rate Outside Containment Was Greater than Program Limit.Caused by Weld Defect.Isolated Leak & Cut Out & Replaced Leaking Pipe ML17264A8271997-03-0303 March 1997 LER 97-001-00:on 970131,discovered Service Water Temp Was Less than Specified Value.Caused by non-representative Method of Monitoring.Increased Water Temp in Screenhouse Bay to Greater than 35 Degrees F.W/970303 Ltr ML17264A8071997-01-22022 January 1997 LER 96-015-00:on 961223,discovered Thermally Induced Overpressure Transient Could Occur.Caused by Thermal Expansion of Fluid During Design Basis Accident Condition. Installed Relief Valve on Affected line.W/970122 Ltr ML17264A7471996-11-27027 November 1996 LER 96-013-00:on 961029,circuit Breakers Closed While in Mode 3 & Resulted in Condition Prohibited by TS Due to Personnel Error.Circuit Breakers for MOV-878B & MOV-878D Were re-opened.W/961127 Ltr ML17264A6051996-09-19019 September 1996 LER 96-012-00:on 960820,feedwater Transient Occurred,Due to Closure of Feedwater Regulating Valve,Causing Lo Lo Steam Generator Level Reactor Trip.Sgs Were Restored & Missing Screw in 1/P-476 Was replaced.W/960919 Ltr ML17264A6061996-09-19019 September 1996 LER 96-009-01:on 960723,leakage Outside Containment Occurred,Due to Weld Defect,Resulting in Leak Rate Greater than Program Limits.Source of Leakage Isolated from RWST by Freeze Seal,Allowing Exit from ITS LCO 3.0.3.W/960919 Ltr ML17264A5911996-09-0505 September 1996 LER 96-011-00:on 960807,improper Configuration of Circuit Breaker Occurred,Due to Undetected Internal Interference, Resulting in Automatic Start of Both Auxiliary Feedwater Pumps.Running AFW Pumps Were secured.W/960905 Ltr ML17264A5921996-09-0505 September 1996 LER 96-010-00:on 960806,latching of Main Turbine While in Mode 4 Occurred,Due to Defective Procedure,Resulting in Automatic Start of Auxiliary Feedwater Pump.Caused by Defective Maint Procedure.Procedure revised.W/960905 Ltr ML17264A5891996-08-22022 August 1996 LER 96-009-00:on 960723,determined Leak on Piping Sys Outside Containment Greater than Program Limit.Caused by Weld Defect.Pipe & Socket Welds Were Cut Out & Replaced. W/960822 Ltr ML17264A5781996-08-0606 August 1996 LER 96-008-00:on 960707,main Feedwater Pump Breakers Opened. Caused by Change in Seal Water Differential Pressure Occurred During Sys Realignment.Afw Flow Controlled as Desired to Maintain S/G level.W/960806 Ltr ML17264A5561996-07-12012 July 1996 LER 96-007-00:on 960612,CR Operators Identified Control Rods Misaligned & Not Moving in Proper Sequence.Caused by Faulty Firing Circuit Card in Rod Control Sys.Faulty Firing Circuit Card in 1BD Power Cabinet replaced.W/960712 Ltr ML17264A5421996-06-20020 June 1996 LER 96-006-00:on 960521,discovered Containment Penetration Not in Required Status.Caused by Personnel Error.Installed Flange Inside Containment Penetration 2.W/960620 Ltr ML17264A5411996-06-17017 June 1996 LER 96-005-00:on 960516,PORC Determined Deficient Procedures Do Not Meet SRs for Testing safety-related Logic Circuits. Caused by Inadequancies in Individual Testing Procedures. Procedures Re Improved TSs revised.W/960617 Ltr ML17264A5051996-05-17017 May 1996 LER 96-003-01:on 960308,identified That Both Pressurizer PORVs Inoperable Concurrently Due to Disconnection of Flex Hose to Both PORV Actuators to Install air-sets for Benchset & Limit Switch Activities.Hpes Completed ML17264A4481996-04-0808 April 1996 LER 96-003-00:on 960308,both Pressurizer Relief Valves Inoperable.Hpes Evaluation Is Being Conducted to Determined Cause of Event.C/As:Both PORVs restored.W/960408 Ltr ML17264A4471996-04-0808 April 1996 LER 96-002-00:on 960307,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump.C/As: Thermography performed.W/960408 Ltr ML17264A4101996-03-18018 March 1996 LER 96-001-00:on 950504,inservice Test Not Performed During Refueling Outage.Caused by Inadequate Tracking of Surveillance Frequency.Valve Test Performed & Disassembled. W/960318 Ltr ML17264A2971995-12-14014 December 1995 LER 95-009-00:on 950817,surveillance Was Not Performed Due to Improper Application of TS Requirements Resulting in TS Violation.Testing of MOV-515 Was Performed on 951115.W/ 951214 Ltr ML17264A1711995-09-25025 September 1995 LER 95-008-00:on 950825,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump That Resulted in Manual Rt.Returned S/G Levels to Normal Operating levels.W/950925 Ltr 1999-09-22
[Table view] Category:RO)
MONTHYEARML17265A7541999-09-22022 September 1999 LER 99-011-00:on 990823,small Tears Were Discovered in Flexible Duct Work Connector at Inlet of CR HVAC Sys Return Air Fan (AKF08).Caused by in-leakage Greater than That Assumed.Implemented Temporary Mod 99-029.With 990922 Ltr ML17265A7431999-08-24024 August 1999 LER 99-004-01:on 990412,discovered That Containment Recirculation Fan Chevron Separator Vanes Were Installed Backwards.Caused by Improper Assembly by Mfg.Moisture Separator Vanes Were Dismantled & Correctly re-installed ML17265A7181999-07-23023 July 1999 LER 99-007-01:on 990423,reactor Trip Occurred Due to Instrument & Control Technicians Inadvertently Pulling Fuses from Wrong Nuclear Instrument Channel.Setpoint Adjustments Were Completed by Different Crew of Technicians ML17265A7081999-07-22022 July 1999 LER 98-003-02:on 980904,actuations of CR Emergency Air Treatment Sys Was Noted Due to Invalid Causes.Caused by Various Degraded Components in CR RM Sys.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored ML17265A7031999-07-19019 July 1999 LER 99-S01-00:on 990617,determined That Temporary Unescorted Access Had Been Granted to Contractor Employee.Caused by Incomplete Info Re Circumstances of Individual Military Separation.Individual Access Was Revoked.With 990719 Ltr ML17265A7021999-07-15015 July 1999 LER 99-010-00:on 990615,ventilation Isolation of Auxiliary Bldg Occurred When Auxiliary Bldg Gas Radiation Monitor R-14 Reached High Alarm Setpoint.Cr Operators Rest Auxiliary Bldg Ventilation Isolation Signal.With 990715 Ltr ML17265A6851999-06-21021 June 1999 LER 99-001-01:on 990222,deficiencies in NSSS Vendor steam- Line Brake Mass & Energy Release Analysis Results in Plant Being Outside Design Bases Occurred.Caused by Deficiencies in W.Temporary Administrative Replaced.With 990621 Ltr ML17265A6661999-06-0202 June 1999 LER 99-009-00:on 990503,instrumentation Declared Inoperable in Multiple Channels Resulted in Condition Prohibited by Ts. Caused by Unanticipated High Frequency AC Voltage Ripple. Entered TS LCO 3.0.3.With 990602 Ltr ML17309A6541999-05-27027 May 1999 LER 99-008-00:on 990427,overtemperature Delta T Reactor Trip Occurred Due to Faulted Bistable During Calibr of Redundant Channel.Plant Was Stabilized in Mode 3 & Faulted Bistable Was Subsequently Replaced.With 990527 Ltr ML17265A6631999-05-24024 May 1999 LER 99-007-00:on 990423,technicians Inadvertently Pulled Fuses from Wrong Nuclear Instrument Cahnnel,Causing Reactor Trip,Due to High Range Flux Trip.Caused by Personnel Error. Labeling Scheme Improved ML17265A6601999-05-21021 May 1999 LER 99-006-00:on 990421,start of turbine-driven Auxiliary Feedwater Pump Was Noted.Caused by MOV Being Left in Open Position.Closed Manual Isolation Valve to Secure Steam to Pump.With 990521 Ltr ML17265A6441999-05-13013 May 1999 LER 99-005-00:on 990413,undervoltage Signal of Safeguards Bus During Testing Resulted in Automatic Start of B Edg. Caused by Personnel Error.Blown Fuse Was Replaced & Offsite Power Was Restored to Safeguards Bus 17.With 990513 Ltr ML17265A6431999-05-12012 May 1999 LER 99-004-00:on 990412,discovered That Containment Recirculation Fan Moisture Separator Vanes Were Incorrectly Installed,Per 10CFR21.Caused by Improper Assembly by Mfg. Subject Vanes Were Dismantled & Correctly re-installed ML17265A6141999-03-31031 March 1999 LER 99-003-00:on 990301,two Main Steam non-return Check Valves Were Declared Inoperable Due to Exceedance of Acceptance Criteria.Caused by Changes in Methodology & Matls.Packing Gland Torque Will Be Adjusted.With 990331 Ltr ML17265A6131999-03-29029 March 1999 LER 99-002-00:on 990227,discovered That Surveillance Had Not Been Performed at Frequency,Per Ts.Caused by Personnel Error.Procedure O-6.13 Will Be Evaluated for Enhancement Documentation of Completion of ITS Srs.With 990329 Ltr ML17265A6061999-03-24024 March 1999 LER 99-001-00:on 990222,plant Was Noted Outside Design Basis.Caused by Deficiencies in NSSS Vendor Slb Mass & Energy Release.Placed Temporary Administrative Restriction 40 Degrees F Max on Screenhouse Bay Temp ML17265A4951998-12-21021 December 1998 LER 98-005-00:on 981120,loss of 34.5 Kv Offsite Power Circuit 751,resulted in Automatic Start of B Edg.Caused by Faulted Cable Splice.Performed Appropriate Actions of Abnormal Procedure AP-ELEC.1.With 981221 Ltr ML17265A4931998-12-17017 December 1998 LER 98-004-00:on 971030,determined That Improperly Performed Surveillance Resulted in Condition Prohibited by Ts.Caused by Procedure non-adherence.Appropriate Calibr Procedures Were Properly Performed with 24 H of Condition Discovery ML17265A4691998-11-25025 November 1998 LER 98-003-01:on 980904,actuations of CR Emergency Air Treatment Systems (Creats) Occurred.Caused by Radon build-up During Temp Inversion.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored to CR ML17265A4271998-10-0505 October 1998 LER 98-003-00:on 980904,actuations of CR Emergency Air Treatment Sys Occurred.Caused by Radon build-up During Temp Inversion.Air Samples Were Taken & Determined That Source of Radiation Was Naturally Occurring Radon.With 981005 Ltr ML17265A3671998-07-14014 July 1998 LER 98-002-00:on 971019,CR Emergency Air Treatment Sys Actuating Function Was Not Operable.Caused by Mispositioned Switch.Revised Procedure CPI-MON-R37.W/980714 Ltr ML17265A1921998-03-11011 March 1998 LER 98-001-00:on 980209,discovered That Boraflex Degradation in SPF Was Greater than Was Assumed.Caused by Dissolution of Boron on Boraflex Matrix,Per 10CFR50.21.Removed Spent Fuel Assemblies from Selected Degraded Storage Rack Cells ML17265A1641998-02-0606 February 1998 LER 97-007-01:on 971117,reactor Engineer Recognized That Neutron Flux Low Range Trip Circuitry for Channel Was Not in Tripped Condition as Required.Caused by Technical Inadequacies.Channel Defeat Will Be Identified ML17265A1601998-02-0606 February 1998 LER 97-006-01:on 971103,verification of B Concentration Was Not Performed Due to Misinterpretation of Event Sequence. Audible Count Rate Function Was Restored to Operable Status ML17264B1441997-12-17017 December 1997 LER 97-007-00:on 971117,NF Low Range Trip Circuitry for Channel N-44 Was Not Placed in Tripped Condition.Caused by Technical Inadequacies in Procedures.Implemented EWR 4862 to Resolve Design deficiency.W/971217 Ltr ML17264B1291997-12-0303 December 1997 LER 97-006-00:on 971103,NIS Audible Count Rate Function Was Inoperable.Caused by Misinterpretation of Event Sequence Due to Not Verifying Boron Concentration.B Verification Occurred Every 12 H Per ITS LCO Action 3.9.2.C.3.W/971203 Ltr ML17264B1271997-12-0101 December 1997 LER 97-005-00:on 971031,undetected Unblocking of SI Actuation Signal Occurred at Low Pressure Condition,Due to Faulty Bistable Which Resulted in Inadvertent SI Actuation Signal.Sias,Ci & CVI Signals Were Reset ML17264B1211997-11-24024 November 1997 LER 97-004-00:on 971024,radiation Monitor Alarm Were Noted Due to Higher than Normal Radioactive Gas Concentration Resulted in Cvi.New R-12 Alarm Setpoint Was Maintained for Duration of Refueling Outage ML17264B0461997-09-29029 September 1997 LER 97-003-01:on 970730,bistable Instrument Trip Setpoint Could Have Exceeded Allowable Value.Caused by Insufficient Existing Margin Between Trip Setpoint & Allowable Value. Held Switches in Tripped configuration.W/970929 Ltr ML17264B0111997-08-27027 August 1997 LER 97-003-00:on 970730,high Steam Flow Bistable Instrument Setpoint Plus Instrument Uncertainty Could Exceed Allowable Value in ITS Was Identified.Caused by Entry Into ITS LCO 3.0.3.Switches Placed in Tripped configuration.W/970827 Ltr ML17264A9941997-08-19019 August 1997 LER 97-002-00:on 970720,34.5 Kv Offsite Power Circuit 751 Was Lost.Caused by Automatic Actuation of B Emergency DG Due to Undervoltage on Safeguards Buses 16 & 17.Offsite Power Restored to Safeguards Buses 16 & 17.W/970819 Ltr ML17264A9911997-08-11011 August 1997 LER 96-009-02:on 960723,determined That Leak Rate Outside Containment Was Greater than Program Limit.Caused by Weld Defect.Isolated Leak & Cut Out & Replaced Leaking Pipe ML17264A8271997-03-0303 March 1997 LER 97-001-00:on 970131,discovered Service Water Temp Was Less than Specified Value.Caused by non-representative Method of Monitoring.Increased Water Temp in Screenhouse Bay to Greater than 35 Degrees F.W/970303 Ltr ML17264A8071997-01-22022 January 1997 LER 96-015-00:on 961223,discovered Thermally Induced Overpressure Transient Could Occur.Caused by Thermal Expansion of Fluid During Design Basis Accident Condition. Installed Relief Valve on Affected line.W/970122 Ltr ML17264A7471996-11-27027 November 1996 LER 96-013-00:on 961029,circuit Breakers Closed While in Mode 3 & Resulted in Condition Prohibited by TS Due to Personnel Error.Circuit Breakers for MOV-878B & MOV-878D Were re-opened.W/961127 Ltr ML17264A6051996-09-19019 September 1996 LER 96-012-00:on 960820,feedwater Transient Occurred,Due to Closure of Feedwater Regulating Valve,Causing Lo Lo Steam Generator Level Reactor Trip.Sgs Were Restored & Missing Screw in 1/P-476 Was replaced.W/960919 Ltr ML17264A6061996-09-19019 September 1996 LER 96-009-01:on 960723,leakage Outside Containment Occurred,Due to Weld Defect,Resulting in Leak Rate Greater than Program Limits.Source of Leakage Isolated from RWST by Freeze Seal,Allowing Exit from ITS LCO 3.0.3.W/960919 Ltr ML17264A5911996-09-0505 September 1996 LER 96-011-00:on 960807,improper Configuration of Circuit Breaker Occurred,Due to Undetected Internal Interference, Resulting in Automatic Start of Both Auxiliary Feedwater Pumps.Running AFW Pumps Were secured.W/960905 Ltr ML17264A5921996-09-0505 September 1996 LER 96-010-00:on 960806,latching of Main Turbine While in Mode 4 Occurred,Due to Defective Procedure,Resulting in Automatic Start of Auxiliary Feedwater Pump.Caused by Defective Maint Procedure.Procedure revised.W/960905 Ltr ML17264A5891996-08-22022 August 1996 LER 96-009-00:on 960723,determined Leak on Piping Sys Outside Containment Greater than Program Limit.Caused by Weld Defect.Pipe & Socket Welds Were Cut Out & Replaced. W/960822 Ltr ML17264A5781996-08-0606 August 1996 LER 96-008-00:on 960707,main Feedwater Pump Breakers Opened. Caused by Change in Seal Water Differential Pressure Occurred During Sys Realignment.Afw Flow Controlled as Desired to Maintain S/G level.W/960806 Ltr ML17264A5561996-07-12012 July 1996 LER 96-007-00:on 960612,CR Operators Identified Control Rods Misaligned & Not Moving in Proper Sequence.Caused by Faulty Firing Circuit Card in Rod Control Sys.Faulty Firing Circuit Card in 1BD Power Cabinet replaced.W/960712 Ltr ML17264A5421996-06-20020 June 1996 LER 96-006-00:on 960521,discovered Containment Penetration Not in Required Status.Caused by Personnel Error.Installed Flange Inside Containment Penetration 2.W/960620 Ltr ML17264A5411996-06-17017 June 1996 LER 96-005-00:on 960516,PORC Determined Deficient Procedures Do Not Meet SRs for Testing safety-related Logic Circuits. Caused by Inadequancies in Individual Testing Procedures. Procedures Re Improved TSs revised.W/960617 Ltr ML17264A5051996-05-17017 May 1996 LER 96-003-01:on 960308,identified That Both Pressurizer PORVs Inoperable Concurrently Due to Disconnection of Flex Hose to Both PORV Actuators to Install air-sets for Benchset & Limit Switch Activities.Hpes Completed ML17264A4481996-04-0808 April 1996 LER 96-003-00:on 960308,both Pressurizer Relief Valves Inoperable.Hpes Evaluation Is Being Conducted to Determined Cause of Event.C/As:Both PORVs restored.W/960408 Ltr ML17264A4471996-04-0808 April 1996 LER 96-002-00:on 960307,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump.C/As: Thermography performed.W/960408 Ltr ML17264A4101996-03-18018 March 1996 LER 96-001-00:on 950504,inservice Test Not Performed During Refueling Outage.Caused by Inadequate Tracking of Surveillance Frequency.Valve Test Performed & Disassembled. W/960318 Ltr ML17264A2971995-12-14014 December 1995 LER 95-009-00:on 950817,surveillance Was Not Performed Due to Improper Application of TS Requirements Resulting in TS Violation.Testing of MOV-515 Was Performed on 951115.W/ 951214 Ltr ML17264A1711995-09-25025 September 1995 LER 95-008-00:on 950825,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump That Resulted in Manual Rt.Returned S/G Levels to Normal Operating levels.W/950925 Ltr 1999-09-22
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML17265A7601999-10-0505 October 1999 Part 21 Rept Re W2 Switch Supplied by W Drawn from Stock, Did Not Operate Properly After Being Installed on 990409. Switch Returned to W on 990514 for Evaluation & Root Cause Analysis ML17265A7621999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Re Ginna Npp.With 991008 Ltr ML17265A7531999-09-23023 September 1999 Part 21 Rept Re Corrective Action & Closeout of 10CFR21 Rept of Noncompliance Re Unacceptable Part for 30-4 Connector. Unacceptable Parts Removed from Stock & Scrapped ML17265A7541999-09-22022 September 1999 LER 99-011-00:on 990823,small Tears Were Discovered in Flexible Duct Work Connector at Inlet of CR HVAC Sys Return Air Fan (AKF08).Caused by in-leakage Greater than That Assumed.Implemented Temporary Mod 99-029.With 990922 Ltr ML17265A7471999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Re Ginna Npp.With 990909 Ltr ML17265A7431999-08-24024 August 1999 LER 99-004-01:on 990412,discovered That Containment Recirculation Fan Chevron Separator Vanes Were Installed Backwards.Caused by Improper Assembly by Mfg.Moisture Separator Vanes Were Dismantled & Correctly re-installed ML17265A7341999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Re Ginna Npp.With 990806 Ltr ML17265A7291999-07-29029 July 1999 Interim Part 21 Rept Re safety-related DB-25 Breaker Mechanism Procured from W Did Not Pas Degradatin Checks When Drawn from Stock to Be Installed Into BUS15/03A.Holes Did Not line-up & Tripper Pan Bent ML17265A7181999-07-23023 July 1999 LER 99-007-01:on 990423,reactor Trip Occurred Due to Instrument & Control Technicians Inadvertently Pulling Fuses from Wrong Nuclear Instrument Channel.Setpoint Adjustments Were Completed by Different Crew of Technicians ML17265A7081999-07-22022 July 1999 LER 98-003-02:on 980904,actuations of CR Emergency Air Treatment Sys Was Noted Due to Invalid Causes.Caused by Various Degraded Components in CR RM Sys.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored ML17265A7131999-07-22022 July 1999 Special Rept:On 990407,radiation Monitor RM-14A Was Declared Inoperable.Caused by Failed Communication Link from TSC to Plant Process Computer Sys.Communication Link Was re-established & RM-14A Was Declaed Operable on 990521 ML17265A7031999-07-19019 July 1999 LER 99-S01-00:on 990617,determined That Temporary Unescorted Access Had Been Granted to Contractor Employee.Caused by Incomplete Info Re Circumstances of Individual Military Separation.Individual Access Was Revoked.With 990719 Ltr ML17265A7211999-07-19019 July 1999 ISI Rept for Third Interval (1990-1999) Third Period, Second Outage (1999) at Re Ginna Npp. ML17265A7021999-07-15015 July 1999 LER 99-010-00:on 990615,ventilation Isolation of Auxiliary Bldg Occurred When Auxiliary Bldg Gas Radiation Monitor R-14 Reached High Alarm Setpoint.Cr Operators Rest Auxiliary Bldg Ventilation Isolation Signal.With 990715 Ltr ML17265A7661999-06-30030 June 1999 1999 Rept of Facility Changes,Tests & Experiments Conducted Without Prior NRC Approval for Jan 1998 Through June 1999, Per 10CFR50.59.With 991020 Ltr ML17265A7011999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Re Ginna Npp.With 990712 Ltr ML17265A6851999-06-21021 June 1999 LER 99-001-01:on 990222,deficiencies in NSSS Vendor steam- Line Brake Mass & Energy Release Analysis Results in Plant Being Outside Design Bases Occurred.Caused by Deficiencies in W.Temporary Administrative Replaced.With 990621 Ltr ML17265A6761999-06-16016 June 1999 Part 21 Rept Re Defects & noncompliances,10CFR21(d)(3)(ii), Which Requires Written Notification to NRC on Identification of Defect or Failure to Comply. Relays Were Returned to Eaton for Evaluation & Root Cause Analysis ML17265A6661999-06-0202 June 1999 LER 99-009-00:on 990503,instrumentation Declared Inoperable in Multiple Channels Resulted in Condition Prohibited by Ts. Caused by Unanticipated High Frequency AC Voltage Ripple. Entered TS LCO 3.0.3.With 990602 Ltr ML17265A6681999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Re Ginna Nuclear Power Plant.With 990608 Ltr ML17265A6651999-05-27027 May 1999 Interim Rept Re W2 Control Switch,Procured from W,Did Not Operate Satisfactorily When Drawn from Stock to Be Installed in Main Control Board for 1C2 Safety Injection Pump. Estimated That Evaluation Will Be Completed by 991001 ML17309A6541999-05-27027 May 1999 LER 99-008-00:on 990427,overtemperature Delta T Reactor Trip Occurred Due to Faulted Bistable During Calibr of Redundant Channel.Plant Was Stabilized in Mode 3 & Faulted Bistable Was Subsequently Replaced.With 990527 Ltr ML17265A6631999-05-24024 May 1999 LER 99-007-00:on 990423,technicians Inadvertently Pulled Fuses from Wrong Nuclear Instrument Cahnnel,Causing Reactor Trip,Due to High Range Flux Trip.Caused by Personnel Error. Labeling Scheme Improved ML17265A6601999-05-21021 May 1999 LER 99-006-00:on 990421,start of turbine-driven Auxiliary Feedwater Pump Was Noted.Caused by MOV Being Left in Open Position.Closed Manual Isolation Valve to Secure Steam to Pump.With 990521 Ltr ML17265A6591999-05-17017 May 1999 Part 21 Rept Re Relay Deficiency Detected During pre-installation Testing.Caused by Incorrectly Wired Relay Coil.Relays Were Returned to Eaton Corp for Investigation. Relays Were Repaired & Retested ML17265A6441999-05-13013 May 1999 LER 99-005-00:on 990413,undervoltage Signal of Safeguards Bus During Testing Resulted in Automatic Start of B Edg. Caused by Personnel Error.Blown Fuse Was Replaced & Offsite Power Was Restored to Safeguards Bus 17.With 990513 Ltr ML17265A6431999-05-12012 May 1999 LER 99-004-00:on 990412,discovered That Containment Recirculation Fan Moisture Separator Vanes Were Incorrectly Installed,Per 10CFR21.Caused by Improper Assembly by Mfg. Subject Vanes Were Dismantled & Correctly re-installed ML17265A6381999-05-0707 May 1999 Part 21 Rept Re Replacement Turbocharger Exhaust Turbine Side Drain Port Not Functioning as Design Intended.Caused by Manufacturing Deficiency.Turbocharger Was Reaasembled & Reinstalled on B EDG ML17265A6391999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Re Ginna Nuclear Power Plant.With 990510 Ltr ML17265A6361999-04-23023 April 1999 Part 21 Rept Re Power Supply That Did Not Work Properly When Drawn from Stock & Installed in -25 Vdc Slot.Power Supply Will Be Sent to Vendor to Perform Failure Mode Assessment.Evaluation Will Be Completed by 991001 ML17265A6301999-04-18018 April 1999 Rev 1 to Cycle 28 COLR for Re Ginna Npp. ML17265A6251999-04-15015 April 1999 Special Rept:On 990309,halon Systems Were Removed from Svc & Fire Door F502 Was Blocked Open.Caused by Mods Being Made to CR Emergency Air Treatment Sys.Continuous Fire Watch Was Established with Backup Fire Suppression Equipment ML17265A6551999-04-0909 April 1999 Initial Part 21 Rept Re Mfg Deficiency in Replacement Turbocharger for B EDG Supplied by Coltec Industries. Deficiency Consisted of Missing Drain Port in Intermediate Casing.Required Oil Drain Port Machined Open ML17265A6291999-03-31031 March 1999 Rev 0 to Cycle 28 COLR for Re Ginna Npp. ML17265A6241999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Ginna Station.With 990409 Ltr ML17265A6141999-03-31031 March 1999 LER 99-003-00:on 990301,two Main Steam non-return Check Valves Were Declared Inoperable Due to Exceedance of Acceptance Criteria.Caused by Changes in Methodology & Matls.Packing Gland Torque Will Be Adjusted.With 990331 Ltr ML17265A6131999-03-29029 March 1999 LER 99-002-00:on 990227,discovered That Surveillance Had Not Been Performed at Frequency,Per Ts.Caused by Personnel Error.Procedure O-6.13 Will Be Evaluated for Enhancement Documentation of Completion of ITS Srs.With 990329 Ltr ML17265A6061999-03-24024 March 1999 LER 99-001-00:on 990222,plant Was Noted Outside Design Basis.Caused by Deficiencies in NSSS Vendor Slb Mass & Energy Release.Placed Temporary Administrative Restriction 40 Degrees F Max on Screenhouse Bay Temp ML17265A5661999-03-0101 March 1999 Rev 26 to QA Program for Station Operation. ML17265A5961999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Ginna Nuclear Power Plant.With 990310 Ltr ML17265A5371999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Re Ginna Nuclear Power Plant.With 990205 Ltr ML17265A5951998-12-31031 December 1998 Rg&E 1998 Annual Rept. ML17265A5001998-12-21021 December 1998 Rev 26 to QA Program for Station Operation. ML17265A4951998-12-21021 December 1998 LER 98-005-00:on 981120,loss of 34.5 Kv Offsite Power Circuit 751,resulted in Automatic Start of B Edg.Caused by Faulted Cable Splice.Performed Appropriate Actions of Abnormal Procedure AP-ELEC.1.With 981221 Ltr ML17265A4931998-12-17017 December 1998 LER 98-004-00:on 971030,determined That Improperly Performed Surveillance Resulted in Condition Prohibited by Ts.Caused by Procedure non-adherence.Appropriate Calibr Procedures Were Properly Performed with 24 H of Condition Discovery ML17265A4761998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Re Ginna Nuclear Power Plant.With 981210 Ltr ML17265A4691998-11-25025 November 1998 LER 98-003-01:on 980904,actuations of CR Emergency Air Treatment Systems (Creats) Occurred.Caused by Radon build-up During Temp Inversion.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored to CR ML17265A4531998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for Re Ginna Nuclear Power Plant.With 981110 Ltr ML17265A4271998-10-0505 October 1998 LER 98-003-00:on 980904,actuations of CR Emergency Air Treatment Sys Occurred.Caused by Radon build-up During Temp Inversion.Air Samples Were Taken & Determined That Source of Radiation Was Naturally Occurring Radon.With 981005 Ltr ML17265A4291998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Re Ginna Nuclear Power Plant.With 981009 Ltr 1999-09-30
[Table view] |
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ACCELERATED DISJBUTION DEMONST~ION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RXDS)ACCESSION NBR: 9103130115 DOC.DATE: 91/03/08 NOTARIZED:
NO FACIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit, 1, Rochester G AUTH.NAME AUTHOR AFFILIATION BACKUS,W.H.
Rochester Gas&Electric Corp.MECREDY,R.C.
Rochester Gas&Electric Corp.RECIP.NAME RECIPIENT AFFILIATION DOCKET 05000244
SUBJECT:
LER 90-017-01:on 901212,two DC switches opened causing disabling of manual automatic actuation of safeguards sequence initiation.
Caused by inadequate procedures.
Procedures revised.W/910308 ltr.DISTRIBUTION CODE: IE22D COPXES RECEIVED:LTR ENCL SIZE: TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.NOTES:License Exp date in accordance with 10CFR2,2.109(9/19/72).
D 05000244 A D RECIPIENT ID CODE/NAME PD1-3 LA JOHNSON,A INTERNAL: ACNW AEOD/DSP/TPAB NRR/DET/ECMB 9H NRR/DLPQ/LHFB11 NRR/DOEA/OEAB NRR/DST/SELB 8D N LBBD1 02 RGN1 FILE 01 EXTERNAL: EG&G BRYCE,J.H NRC PDR NSIC MURPHY,G.A COPIES LTTR ENCL 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3 1 1 1 1 RECIPIENT ID CODE/NAME PD1-3 PD AEOD/DOA AEOD/ROAB/DSP NRR/DET/EMEB 7E NRR/DLPQ/LPEB10 NRR/DREP/PRPB11 NRR/DST/SICB 7E NRR/DST/SRXB 8E RES/DSIR/EIB L ST LOBBY WARD NSXC MAYS,G NUDOCS FULL TXT COPIES LTTR ENCL 1 1 1 1 2 2 1 1 1 1 2 2 1 1.1 1'1 1 1 1 1 1 1 D R tyfl'tY+~f D NOTE TO ALL"RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK, ROOM P 1-37 (EXT.20079)TO ELIMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!TOTAL NUMBER OF COPIES REQUIRED: LTTR 31 ENCL 31 D D n
C~'iltd~~~lfllkl!Ill!~
ROCHESTER GAS AND ELECTRIC CORPORATION ROBERT C.MECREDY Vice President Cinna Nuclear Producrion r roar srAsc~89 EAST AVENUE, ROCHESTER N.Y.14649-0001 TELEPHONE AREA COOET16 546'2700 March 8, 1991 U.S.Nuclear Regulatory Commission Document Control Desk Washington, DC 20555
Subject:
LER 90-017, (Revision 1)Opening of DC Switches (Procedural Inadequacy)
Disables Manual and Auto Actuation of Safeguards Sequence Initiation Causing a Condition Outside the Design Basis of the Plant R.E.Ginna Nuclear Power Plant Docket No.50-244 In accordance with 10 CFR 50.73, Licensee Event Report System, item (a)(2)(ii)(B), which requires a report of,"any event or condition that resulted in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded, or resulted in the nuclear power plant being in a condition that was outside the design basis of the plant", the attached Licensee Event Report LER 90-017 is hereby submitted.
This revision is necessary to revise section IV (Analysis of Event)due to new information being received.This event has in no way affected the public's health and safety.Ver truly yours, OLc Robert C.Mec edy xc: U.S.Nuclear Regulatory Commission Region I 475 Allendale Road King of Prussia, PA 19406 Ginna USNRC Senior Resident Inspector 9103130115 91030S PDR ADOCK 05000244 S PDR
~IAC Aeeae IN>>O$1 LICENSEE EVENT REPORT ILER)UA IIVCLIAA AIOVLATOA V COINIMAIN AceAovlo oNI INL$IN 0lov CA&VIII I/$1/~I CACIUTY NAeel lll R.E.Ginna Nuclear Power Plant OOCAIT Nve>>IA Ql 0 6 0 0 0 2 4 4 T Of 1 5"'~'" Opening of DC Switches Disables Manual and Auto Actuation o Safeguards ence In>.tiation, Causin a Condition Outside the Desi Basis of the Plant UONTII OAY YCA1 IVCNT OATS III YCAI LCA NVe>>CA III I I 0 U I eI e>A L~eUUe~1 AevAaUe wlweA AleOAT OATI Ih UONTN OAY YIAA OOCAIT NVUICA>>I 0 6 0 0 0~ACIUTY N*ULI OTNI1 CACIUTIII INVOLVIO ell 1 2 1 2 9 0 9 0 0 1 7 0 1 0 30891 0 6 0 0 0 OeIAATINO IIOOC I~I~OIVCA LCVIL p p IIL INN I I I ILI IO.CNIe Ill I Ill IO.AN W I I II>>I IOANWII II>>I$O.CNWIIIIII X TN>>ACCOAT>>WIUITTIO eVAIUAN'f T Il.eOI III Tl.eNleI NMlellll NMWQI N.f$W Q I I II N.f$4 I QI I II N.T Sle IQI I Wl N.TIWQIINI N.NNIQhet N,f III I Ql leel NP INI Q IIIAAIAI~O.f$NIIIIIe>>I>>l IO.TIWQllal 0 TIIC 1lovl1CUINTI oe IlcJA II Iceaea eee<<aUae el VU'Ua<<wel 1111 1 LT I ILI TATIW oTIIIA/Caaaaf Ie AAaaeat eaN<<eacla TeeL NAc/N<<SCCA/lICINICI CONTACT COA TNII LC1 ILTI NAUI TILCIUONI NUUIIA Wesley H.Backus AAIA COOl Technical Assistant to the Operations Manager 31 5524-446 COeeellf I ONI LINC COA CACN CoeeeONCNT CAILUAC OIICAIIIO Ue TN>>AICOAT 11$1 CAUII IYITIU coee/oNINT UANU/ACi TVIICA CAUII l Vlf lie COUIONINT UANUCAC TUAIA leOATAIL TO NTIIOI WAW IVYYLIUINTAL AIIOAT IAeICTIO I lee Yll/I/fee, aaeUeeN CCJCCTCO CVCNIIIION OA TC/~ACTAACT/Leaee ee leoI Uea<<, I.A, eA<<eeeaeaea
/IINaa IUceewce lfceeaIINa Aeev lice IxeICTIO WIIIICCION OATI IIII 1:Yga a'(%j""'$>gg~U ONTII CAY Y CAN On December 12, 1990, at 2310 EST, with the reactor at approximately 34 full power, the Control Room Foreman opened two DC switches, as directed by a Maintenance procedure, causing the disabling of manual (pushbutton) and automatic actuation of the safeguards sequence initiation.
The two DC switches were closed, as directed by the Maintenance procedure, approximately twenty (20)minutes later, restoring manual (pushbutton) and automatic actuation initiation.
The underlying cause of the event was procedure inadequacy due to insufficient attention to detail.Extensive corrective actions are being taken to prevent recurrence, including communication of management expectations, HPES evalua-tions, identifying procedural inadequacies, and a comprehensive upgrade of the procedure change'process.II AC e<<e IN>>4$l
MAC fons$00A I00$I LICENSEE EVENT REPORT ILERI TEXT CONTINUATION V.$, IIVCLTAII ACOULATOIIY COMMISSION AffAOV$0 OM$HO TI$0MIOO f$IIfIA%$$ITI4$fACILITY IIAM 0 III OOCIIKT IIVM0$II IT I LTII IIVM0$II I~I oeQVTnTIAL SUM sovlssln S M~S fAO$ITI R.E.Ginna Nuclear~Plant TSCT IJf esse ONCe e Neoooe.see Oeeeesol JVIIC fons~'el I ITI o s o o o 24 490 01 7 0 1 02 orl 5 PRE-EVR2lT PLANT CONDITIONS The plant was in the process of starting up subsequent'to the plant trip of 12/ll/90 (discussed in LER 90-013).The reactor was at approximately 34 full power, awaiting clearance that secondary chemistry parameters were within specification.
The two Control Room reactor operators were providing full time attention to maintaining steam generator water level (i.e.using"manual" control of feedwater addition)and controlling reactivity due to a Xenon transient (i.e.with manual control of boron concentration).
At approximately 2044 EST, December 12, 1990, the Control Room received Main Control Board Alarm L-14 (Bus 14 Under Voltage Safeguards).
Due to this undervoltage failure, the"A" Emergency Diesel Generator automatically started.By design, it did not close into Bus 14 as Bus 14 was still powered by its normal supply.The Control Room operators dispatched auxiliary operators (AO)to check the Bus 14 Undervoltage Monitoring System Cabinets in the Auxiliary Building and Relay Room.One of the AO's reported to the Control Room operators that the Bus 14 Undervoltage Monitoring System Cabinet in the Auxiliary Building had a burnt odor and the relay indicating lights indicated that at least one relay was not operable.This event is discussed in LER 90-015.The Operations Shift Supervisor
.(SS)notified station electricians of the above indications.
The station electricians then checked the Bus 14 Undervoltage Monitoring System Cabinets and found a faulty solid state switch printed circuit board in the Auxiliary Building Bus 14 Undervoltage Monitoring System Cabinet.These findings were reported to the Control Room.vsC f OAQ$00A teal
~<<AC SccNc SSSA$4SI'LICENSEE EVENT REPORT (LER)TEXT CONTINUATION V.S.NVCLSAII ASOULATOIIY COMMISSION Aft<<OVSO OMS NO SISOMIOC S)tPIIISS 4ISI/IS SACILITY HAM%III R.E.Ginna Nuclear Power Plant TKXT Ill cNrr<<Wce r ctowecI.uM CcNH<<crl ITIC%%d~'CI IITI OOClcKT HVMISA ITI o s o o o 2 4 4 LSII NVMSSII ISI NSAII SCOVCNTIAL ASV<<ION Nvcc TN~Nvr Cr 90 01 7 0 1 AAOS ISI 03 pal 5 The Station Electrical Planner then initiated,"Work Request or Trouble Report" Number 9024136, reviewed applicable drawings and prepared a work package (i.e.work order number 9024136)which included PORC approved Main-tenance procedure M-48.14 (Xsolation of Bus 14 Undervoltage System for Maintenance, Troubleshooting, Rework and Testing).The work package was then reviewed by the Planner Scheduler for compliances with administrative requirements.
The Electrical Planner then performed required notifications of the QC Engineer and a Results and Test technician, and briefed them on the contents of the work package.The Electrical Planner took the work package to the Electric Shop and reviewed it with the two electricians who were to perform the work.The Electrical Planner and two electricians went to the Control Room and reviewed the M-48.14.procedure with the SS.The SS performed a review of the M-48.14 procedure to approve the steps for transferring electrical loads on Bus 14 to the"A" Emergency Diesel Generator.
The SS then gave the M-48.14 procedure to the Control Room Foreman (CRF)to actually perform the operational steps.When the CRF began to read step 5.5.1 of M-48 14, he stopped and questioned the Electrical Planner concerning this step.Step 5.5.1 required the opening of two DC switches.The CRF was concerned with the effect of opening these two DC switches, given the current plant conditions.
Therefore, the CRF and Electrical Planner reviewed the Xnitial Conditions of M-48.14, and re-verified that they were adhering to the procedure requirements.
The Electrical Planner stated to the CRF that this procedure had been performed before.NAC AOAM SSSA I04)I
MAC term 444A (044 I LICENSEE EVENT REPORT{LER)TEXT CONTINUATION U.4.IIUCL4*II 14OULATOAY COMMI44IOH AttAOYEO OM4 HO 4I50&104 4IItIII4$4I414$tACILITY IIAM4 III OOCK4T IIUM44A LTI L4II IIUM44II I4I$4 O V 4 r T I A I.rvr 1 14VISIOr M~1 tAO4 I4I R.E.Ginna Nuclear Power Plant TEXT IJIrrtt rrce r rrvteA t>>trrr4trt NIIC Atnr~'tI l Ill o 5 o o o 24 490-01 7 0 10 40Fl 5 DESCRIPTION OF EVENT A.DATES AND APPROXIMATE TIMES OF MAZOR OCCURRENCES:
o December 12, 1990, 2310 ST: Event Date and Time (i.e.SI DC switches opened)o December 12, 1990, 2330 EST: SI DC switches closed o December 13, 1990, 0102 EST: Event Discovery Date and Time o December 13, 1990, 0150 EST: Nuclear Regulatory Commission (NRC)notified via Emergency Notification System (ENS)B.FAST On December 12, 1990 at 2310 EST, with the reactor at approximately 34 full power, the CRF opened the.two DC switches (required by step 5.5.1 of M-48.14)in the'DC distribution panels on the back of the Control Board.The opening of these switches caused Control Board Alarm L-31 (Safeguards DC Failure)to annunciate.
The receipt of this alarm was questioned at the, time, but the response from the CRF was that the alarm was an expected result of performing step 5.5.1 of M-48.14.Further evaluation of this alarm was deferred to continue with M-48.14.The CRF, continuing with M-48.14, opened the Bus 14 Normal Feed Breaker to allow the"A" Emergency Diesel Generator to tie into Bus 14.This action resulted in momentarily de-energizing the 1B Instrument Bus.The reactor trip relay from Nuclear Instrumentation System Intermediate Range Channel N-36 (powered from this Bus)de-energized and a reactor trip occurred.The reactor trip is discussed in LER 90-016.MAC tOAM 444A i444I
MAC Terna$44A ISA I LICENSEE EVENT REPORT (LER)TEXT CONTINUATION V.S.IIVCLSAA 1SOULATOAY COMMISSIOM A99AOVSO OMS MO SISOWIOl/SIItllISS SISI4$/ACILITY IIAM 4 III R.E.Ginna Nuclear Power Plant TscT w rrr9 race r rrrrA vie eeeeew sAC err~SI IITI OOCIIST MVMSSII I!I o s o o o 24 490 LSII MVMSSII ISI TaovlrnAL HUM A aSYOIQ>~y M 1 0,5 QF1 5 The Control Room operators immediately performed the applicable actions of E-0 (Reactor Trip or Safety Injection) and ES-0.1 (Reactor Trip Response)and stabilized the plant in hot shutdown.After completing the applicable steps of E-0 and ES-0.1, the Control Room operators completed their part of M-48.14, by closing the two DC switches that had been opened in step 5.5.1 of M-48.14.This was accomplished at approximately 2330 EST, December 12, 1990.The oncoming SS, who had been in the Control Room during this event, resumed the evaluation of the consequences of alarm L-31 after plant conditions had stabilized.(The cause of the alarm had already been determined.)
He performed another review of M-48.14 and called other knowledgeable members of the plant staff at their homes (at approximately 0100 EST, December 13, 1990)to discuss his concerns about the effect of opening these two DC switches.After receiving confirmation that his concerns were legiti-mate, he made the proper notifications to higher supervision and the Nuclear Regulatory Commission (NRC).C.D.E.INOPERABLE STRUCTURES 4 COMPONENTS 4 OR SYSTEMS THAT CONTRIBUTED TO THE LRG%T: None.OEM SYSTEMS OR SECONDARY FUNCTIONS AFFECTED: None.METHOD'OF DIScommY: The event was made apparent during the oncoming SS review of the consequences of Control Board Alarm L-31 (Safeguards DC Failure)and subsequent discussions with knowledgeable plant staff.MAC SOAM$44A>94$I 0
MAC torw aaaA IS4al LICENSEE EVENT REPORT (LER)TEXT CONTINUATION V.S.IIVCLSAII ASOVLATOIIY COMMISSIOH AffAOVSO OMS HO SISO&104 arflASS SISI4S f ACILITY NAMa III oocraT IlvMaar Ial I,all IIVMaall Ial SCOVCHTIAL
%VM A Ra+IQIOH M SA~AOa Ial R.E.Ginna Nuclear Power Plant TaxT III neve MMfe e~~oeaecver A'c fons Ia'll II'5 o o o 24 490-01 7 0 106 ovl 5 P OPERATOR ACTION: Factors that influenced operator actions during the event were as follows: 0 The Control Room operators questioned step 5.5.1 in procedure M-48.14, but information in M-48.14, the DC switch labels, and Alarm Response procedure.AR-L-31 did not provide sufficient operational information to determine the consequences of opening these two switches.o The Control Room operators had confidence in a Plant Operating Review Committee (PORC)approved procedure that had also been reviewed by the Electrical Planner.As the event was over prior to discovery, no operator actions other than normal were performed.
G.SAFETY SYSTEM RESPONSES:
None.XXX CAUSE OP EMBFZ A.IMl69)IATE CAUSE: A condition outside the design basis of the plant was caused by the disabling of manual (pushbutton) and automatic actuation of the safeguards sequence initiation (i.e.auto and manual SZ).INTERMEDIATE CAUSE: The disabling of manual (pushbutton) and automatic actuation of the safeguards sequence initiation was caused by switch f12 in the lA DC Distribution Panel and switch g9 in the 1B DC Distribution Panel being open at the same time.Both of these panels are on the back of the Main Control Board.41C SOAQ SSSA la0SI
MAC Sons 494A I94SI LICENSEE EVENT REPORT (LER)TEXT CONTINUATION V.S.IIUCLSAII IIEOULATOAY COMMISSION A99ROVEO OM4 RO SISOMIOA EX9IRES 41414$9ACILITY IIAME III R.E.Ginna Nuclear Power Plant TEXT lll~CWCe M neee4 YA9 aANenel CIVIC Ann~El I ITI o 5 o o o 24 490 LEII HVMCEA 191 SSQUSNTIAL H M A ASYOIO>A p 7 OFl 5 Procedure M-48.14 had been initially written in 1983 for use at hot or cold shutdown conditions.
In 1985, the procedure was modified to allow use only at cold shutdown conditions.
The initial procedure and the revisions were technically correct and received a multi-disciplined review and approval.During 1988, M-48.14 received a major rewrite and Revision 6 became effective March 23, 1989.The purpose of the rewrite was to change the method of feeding Bus 14, and as part of this process the plant mode was changed to"Any Mode of operation." This change received a thorough review prior to becoming effective.
One day later, it was erroneously concluded that certain steps, which had previously been in the procedure for use at cold shutdown, were inadvertently omitted from the current procedure.
Thus, M-48.14 was changed to insert the current step 5.1.1.This change is inappropriate in modes other than cold shutdown, but this was not recognized during the review and approval process.ROOT CAUSE: The root cause was determined to be failure of the organization to attribute sufficient attention to detail in the procedure change process.0 0 A Maintenance procedure which was previously correct, was changed to require inappropriate actions, in that the procedure directed the opening of switches in the DC power supply to the SI sequences during all modes of operation.
The procedure was reviewed by the Plant Operating Review Committee and approved for use by plant management, for all modes of plant operation, although the opening of the two DC switches was clearly intended for use at cold shutdown conditions to prevent spurious SI actuation during Bus transfer to the Emergency Diesel Generators.
+AC AOAM 444A i9 441
NNC Sere M ($4SI L'ICENSEE EVENT REPORT ILERI TEXT CONTINUATION V.S.NVCLSAN ACOULATOIIY COMMISSION ASSAOYKO OMS NO S1$0&IOS/$NSIII%$SISI4$FACILITY NANt III OOCISKT NUMCSII ISI Llll NVMOSII III SSQUSNTIAI, M 1 ASYISION M~A~AOS IS)R.E.Ginna Nuclear Power Plant TEXT IN'mao MSCe N nerre4~~HIIC ANM~'Sl I Ill o s o o o 24 490-01 7-0 80F1 5 A contributing factor is the need for a question-ing attitude.The CRF, in questioning the performance of step 5.1.1 of M-48.14, did not go far enough with his questioning attitude.XV.ANALYSTS OF EVENT This event is reportable in accordance with 10 CFR 50.73, Licensee Event Report System, item (a)(2)(ii)(B), which requires a report of"any event or condition that resulted in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded, or resulted in the nuclear power plant being in a condition that was outside the design basis of the plant", in that the disabling of manual (pushbutton) and automatic actuation of the safeguards sequence initiation placed the plant in a condition outside its design basis.An assessment was performed considering both the safety consequences and implications of this event with the following results and conclusions:
During the above event, manual (pushbutton) and automatic actuation of the safeguards sequence initiation was disabled, however, the various pumps and valves were operable and could be operated by the Control Board'witches.
The Control Room operators perform immediate actions upon reactor trip per procedure E-0.Through these procedural immediate actions the operators evaluate whether a condition requiring safety injection exists, and if required, verify operation of safeguards equipment or manually start and align that equipment.
Their evaluation would be based upon the appropriate annunciator alarms (all of which were unaffected by the DC switch positions), or a review of control board parameter indications (i.e.RCS pressure, Steam Generator pressure, etc.).NAC SON M SSSA<~AS I
ISWC iona 00SA I043 I LICENSEE EVENT REPORT ILERI TEXT CONTINUATION V.S.IIuCLSASI ASOVLATOIIY COMMISNOII
/ASSAOYlO OM0 HO 0ISOWIOS%)ttlAll SI314S FACILITY IIAMl III OOCIIKT IIUMllA Ill Llll MOMOSII I~I SSQMSNTIAL
'SVOIO>M A'M S1 R.E.Ginna Nuclear~Plant TEXT IF WaO CWOt A teyWet,~ASASOASI IYJIC Anti~'S I I I TI o s o o o 24 490 01 7 0 10 90sl 5 The effect of the potential delay in actuating safeguards equipment upon those.events analyzed in the UFSAR was evaluated.
The accidents effected by this action are those accidents which result in depressurization of the primary system causing SI.These are primarily the following:
o Feed Line Break (FLB)o Steam Generator Tube Rupture (SGTR)o Small Break Loss of Coolant Accident (SBLOCA)o Large Break Loss of Coolant Accident (LOCA)o Small Steam Line Break (Small SLB)o Large Steam Line Break (SLB)An analysis of these accidents was performed to determine the effect of the disabling of manual (pushbutton) and automatic actuation of the safeguards sequence initiation with the following results: Feed Line Break This accident was analyzed by the Ginna Updated Final Safety Analysis Report (UFSAR)as'heat up event with auxiliary feedwater available in ten (10)minutes.As a heatup event, RCS pressure never decreased below the SI setpoint, but rapidly increased above the SI pump shutoff head.Therefore, SI was not necessary and auxiliary feedwater, when available within ten (10)minutes, is sufficient to mitigate the event.Operator actions to start auxiliary feedwater within ten (10)minutes is consistent with the Ginna licensing basis.If the FLB was re-evaluated as a cooldown event from 34 power the results would be bounded by a SLB.VAC+0AM SSSA<l00 I
MAC 4re SSSA ITS I LICENSEE EVENT REPORT ILERI TEXT CONTINUATION V.S.IIUCLEAII ASOULATOIIY COMMISNOIe ASSAOVKO OM9 kO 9I SONICS/SIISIA9$SISI4$SACILITY IIASSS Ill OOCIICT IIUMSKR Ill LSII MUM99ll ISI SSQVSNTIAL SVM A A 9 VISION M SA~AOS ISI R.E.Ginna Nuclear Power Plant TaXT IIT~MMCS e~ee SSA9SAM AIAC rene ma SI IITI o s o o o 2 4 4 90 01 7 0 1 100F1 5 Steam Generator Tube Ru ture SGTR is bounded by SBLOCA from the RCS depressurization standpoint.
The leak rate from a SGTR is, small compared to break flow for a SBLOCA.There is no significant effect due to lack of manual (pushbutton) or automatic SI since the main steps in the procedure deal with isolation of the ruptured SG, depressurization of the RCS, and termination of SI.Small Break Loss of Coolant Accident When manual (pushbutton) and automatic SI was de-activated, the reactor was operating at 34 power.The reactor had been at 34 power for approximately ten (10)hours.Prior to that, the reactor had been subcritical for twenty-two (22)hours following a trip.Westinghouse Owner's Group letter WOG 90-113, dated July 2, 1990,"Shutdown LOCA Program-Draft Report", evaluated a mode 4 LOCA using a generic two (2)loop plant with a six (6)inch break assumed to occur two and a half (2.5)hours after shutdown.Acceptable results were obtained provided SI was started ten (10)minutes after the break.Assumptions of the mode 4 LOCA analysis'are compared with the Ginna Event conditions below: WOG MODE 4 GINNA EVENT Decay Heat 1.34 No accumulators available RCS pressure 1000 psig RCS temperature 425oF Decay Heat 0.534 Accumulators available RCS pressure 2235 psig RCS temperature 547 F The availability of accumulators and the lower decay heat offset the higher RCS temperature and pressure.Sufficient time is available to manually start the SI and RHR pumps and open appropriate valves from the Control Room, and to recover from the SBLOCA.In any case, SBLOCA is bounded by LOCA because less time is available for operator action during a Large Break LOCA.No credit was taken for charging flow which by itself could have removed approximately that level of decay~heat.
VAC SCAM SSSA i 9 All
NNC for>>SSSA (S4S IICENSEE EVENT REPORT ILERI TEXT CONTINUATION U.S.NUCLlAN 1SOULATOIIY COMMISSION Aff1OVSO OMS NO SISO&I04/tllfl1SS'SISI4S fACILITY NAMS III OOCKST NUMSSII 11I Lt1 NUMSSN ISI SSQUSNTIAL ASVISION NUM 1 I N M~A~AOS QI R.E.Ginna Nuclear Power Plant TSICT IN'a>>Ce>>>>SVfff.
vlf OS>>SOAN lVAC fWse~VI I ITI o s o o o 2 4 4 90 Ol 7 0 111 OF1 5 Lar e Break Loss of Coolant Accident An assessment of disabling manual (pushbutton) and automatic SI at 34 power was performed by Westinghouse with respect to the LOCA analysis.The assessment assumed the RCS was at 547 F, 2235 psig.The fuel rods were assumed to be at 600 F which would be the approximate pellet and clad temperature at the end-of-blowdown phase.The vessel lower plenum and the lower portion of the core would be covered with accumulator water.Further, it was assumed that, SI must be initiated when the fuel rods are at 1800 F to turn around the cladding temperature before it reaches 2200 F.Decay heat is based on an approximation of power history prior to the event, using the 1971 ANS Model.An adiabatic heatup calculation was performed using properties for a 14 x 14 array Optimum Fuel Assembly (OFA).The calculation indicated SI was necessary in approximately 14 minutes.Simulations on the Ginna specific simulator indicate a less than 2 minute operator response during a LOCA is achievable.
Small Steam Line Break This accident is bounded by the Large SLB because longer times are available for operator response.Lar e Steam Line Break Westinghouse assessed the effect of no manual (pushbutton) or automatic SI on the Steam Line Break analysis.Based on their experiences with Steam Line Break analysis as well as a review of the available margin to the acceptance criteria, it was judged that if the accident were re-analyzed at 34 power with no manual (pushbutton) or automatic SI, acceptable results would be obtained.41C fOAQ SSSA iSASI
MAC Sons$$$A 1$4$1 LICENSEE EVENT REPORT II.ERI TEXT CONTINUATION V.$.HUCL$AII ATOULATOIIY COMMI$$IOM ASSAOVKO OUI IIO$I$0MIOO$)IOIA$$l/$1/8$SACILITY IIAM$111 RoE.Ginna Nuclear Power Plant TSIT III'ssoo MMo~nooooY.oM ooMMMM AtAC ASM~$I I ITI OOCII$T IIUSM$%11I o s o o o 2 4 4 Ltll IIVMO$11 1$l$$CUonTIAL sovlslon~IVM S'M~S 90 01 7 0 1 SAO$1$1 12 0~1 5 Rochester Gas and Electric Corporation (RG&E)performed a computer analysis of the SLB using the Westinghouse LOFTRAN Code.A base case was compared to a case where SI was delayed for ten (10)minutes.The comparison indicated negligible change in minimum DNBR.There was an insigni-ficant change in mass released to containment because mass release is dominated by initial steam generator level and auxiliary feedwater flow, neither of which are affected by delayed SI.Comparing energy out the break for both cases, showed negligible differences.
Therefore, delaying SI has negligible effect on minimum DNBR and mass/energy out the break.In conclusion, delay of manual (pushbutton) and automatic SI with the reactor at 34 power would not cause Non-LOCA events to exceed the acceptance criteria.A delay of approximately 14'inutes in the LOCA can be tolerated without unacceptable results.Based on operator training, this is sufficient time for operator response.Based on the above, it can be concluded that the public's health and safety was assured at all times.V.CORRECTIVE ACTION ACTION TAKEN TO RE'ZURN AFFECTED SYSTEMS TO PRE-~9FZ NORMAL STATUS: The affected system was restored to normal when the two (2)DC switches were closed twenty (20)minutes after they were opened.VAC SCAM$$$A<0'
IIAC>ww SSSA LICENSEE EVENT REPORT ILER)TEXT CONTINUATION V.S.IIUCLSAII IISOULATOIIY COMMISSIOII ASSAOYSO OMS IIO)ISO&I04/SXrlASS SISIISS SACILITY IIAMS III OOCIIST IIVMSSII ISI LSII IIUMS~II ISI SLOMINTIAL lllVISIQN~I 4 1 4 4~AOS ISI R.E.Ginna Nuclear Power Plant o s o o o 24 490 01 7 0 113 OF1 5 B.ACT?ON TAKEN OR PLANNED TO PREVENT RECURRENCE:
Short Term Actions 0 0 Senior Management met with key plant personnel to communicate management expecta-tions for a questioning attitude and attention to detail.These groups included all the operating shifts, the Maintenance planning staff, and PORC members.Policies were issued addressing the Opera-tions Shift Supervisor review of procedures prior to giving authorization to proceed, and the Maintenance planners'esponsi-bilities for Work Package review.0 All plant procedures were screened for possible operational impact inadequacies, and potentially deficient procedures were made unavailable for use.Procedures that were made unavailable for use, but were immediately required for safe plant operation, were carefully reviewed prior to being made available for use.A Human Per f ormance Enhancement System (HPES)evaluation was performed on Control Room activities
'associated with this event, to identify the need for any additional short term corrective actions.Additional actions were identified.
Actions identified by the HPES process were implemented where appropriate, including additional upgrades of switch labels, a more detailed review of Alarm Response procedures, improved wording of pro'cedural steps for Human Factors concerns, and additional information to be made available to the operators.
For all involved operations personnel, their operating experience and training histories were reviewed for adequacy.SAC AOAM SSSA (0 AS I
NAC ro<<M EEEA I04)I rACILITY NAME Ill UCENSEE EVENT REPORT ILER)TEXT CONTINUATION DOCKET NVMEEA IEI VS.NVCLEAII AEOVLATOIIY COMMIEEION ArrROV EO OME NO 3150&104 E)IrIAEE EI31/8$~ACE IEI\R.E.Ginna Nuclear Power Plant TExT Ih'rrrr NMrr<<Mrr<<EE.<<rE aaseow NOMIC fond~'rI IITI LEII NVMEEII (EI<<EAA SECVENTIAL AEVISIQN N M EA o s o o o 24 490 01 7 0 1 4 OF 1 0 An independent assessment of the status of short term actions, and of the procedure screening, was conducted before management authorized restart of the reactor.2~Long Term Actions 0 An HPES evaluation of the procedure change process is being performed.
From this evaluation, recommendations for long term improvements will be implemented.
Among these improvements are the increased involvement of Operations in the review of proposed changes, requirements for more accurate descriptions of proposed changes, and more rigor in the review of changes at PORC meetings.0 To ensure the effectiveness of the short term corrective actions, follow-up evalua-tions will be conducted.
Based on these evaluations, management will determine the need for additional reinforcement of these actions.0 The training programs for Operations personnel, PORC members, and Maintenance planners will be re-evaluated.
We expect to make long term improvements in these programs, and in the content of these programs, and-also in the training programs for other plant personnel.
0 Procedures that are currently unavailable for use will be reviewed in detail prior to release for use.We are expediting the review of those procedures, placing highest priority on those procedures which are expected to be needed during the course of routine operations, to ensure their avail-ability in the near future.NAC rOAM EEEA>EATI 0 l IIAC tore SSSA IS43 I L'ICENSEE EVENT REPORT (LER)TEXT CONTINUATlON V.S.IIUCLEAA AEOULATOIIY COMMITSIOII ANNAOVEO OMS HO)ISO&ION r EXNIAES>II5145 NACILITY IIAME II I R.E.Ginna Nuclear Power Plant TEXT IN'4eCe e teerrC~NcMOoeV IV JIC Awe~1 I I ITI OOCKKT IIUMItll I1I o s o o o 2 4 4 LEII IIUMOEX IN SNOUNHTIAL i NSVOION 4VM 8 H M Ni 90 01 7 0 1~AOE Ill 50rl 5 0 Policies that were initiated as a result of this event will be reviewed for consistency with pre-existing policies and procedures.
where appropriate, existing policies will be altered, superseding the new policies.ADDXTXONAL XNFORMATXON A.FAILED COMPONENTS:
None.B.PREVIOUS LERs ON SIMILAR EVENTS: A similar LER event historical search was conducted with the following results: No documentation of similar LER events with the same root cause at Ginna Station could be identified.
C.SPECXAL COMMENTS None.VAC NOAM SSSA iSOJI 0 I