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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML18107A5031999-08-26026 August 1999 LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr ML18107A4691999-07-28028 July 1999 LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr ML18107A4441999-07-0606 July 1999 LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr ML18107A4211999-07-0202 July 1999 LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr ML18107A4321999-07-0101 July 1999 LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr ML18107A4331999-07-0101 July 1999 LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr ML18107A3951999-06-17017 June 1999 LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr ML18107A3661999-06-0909 June 1999 LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr ML18107A3551999-06-0202 June 1999 LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr ML18107A3541999-06-0101 June 1999 LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr ML18107A2931999-05-12012 May 1999 LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr ML18107A2781999-05-10010 May 1999 LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr ML18107A2791999-05-0404 May 1999 LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr ML18107A2741999-05-0303 May 1999 LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr ML18107A2351999-04-23023 April 1999 LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr ML18106B1471999-03-29029 March 1999 LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr ML18106B0701999-02-16016 February 1999 LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr ML18106B0491999-01-28028 January 1999 LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr ML18106B0401999-01-18018 January 1999 LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr ML18106B0081998-12-24024 December 1998 LER 97-001-01:on 970215,failure to Perform TS Surveillance of Component Cooling Water Sys Check Valves Occurred.Caused by Inadequate Communication Between EOP Group & IST Reviewers.Procedure Revised.With 981224 Ltr ML18106B0021998-12-17017 December 1998 LER 98-015-01:on 980924,improper Installation of Test Equipment to RPS Occurred.Caused by Inadequate 10CFR50.59 Applicability Reviews During Past Revs.Revised Procedures. with 981217 Ltr ML18106A9551998-11-0303 November 1998 LER 96-013-01:on 960711,concluded That Current Gain & Bias Settings Had Rendered Overtemperature Delta Temp Protection Channels Inoperable.Caused by Scaling Error.Licensee Will Revise Scaling Calculations.With 981105 Ltr ML18106A9451998-10-30030 October 1998 LER 97-004-01:on 970408,failure to Comply with TS Action Statement,Dg Start & Inadequate Surveillance Testing,Was Noted.Caused by Inadequate Tracking of Inoperable Equipment. Discussed Event & Lessons Learned.With 981022 Ltr ML18106A9491998-10-22022 October 1998 LER 98-015-00:on 980924,identified Improper Installation of Test Equipment to Rps.Cause Indeterminate.Procedures for Installation of Test Equipment for Collection of State Point Data Were Placed on Administrative Hold.With 981022 Ltr ML18106A9301998-10-21021 October 1998 LER 98-014-00:on 980725,noted Improper Calibr of Liquid Radwaste Effluent Line Radiation Monitor.Caused by Inattention to Detail by Maint Personnel.Channel Calibr Was Successfully Performed on 1R18 on 980821.With 981019 Ltr ML18106A9071998-10-0101 October 1998 LER 98-014-00:on 980918,discovered That Fire Barrier Matl for HVAC Ducts Does Not Meet Required Level of Fire Resistance.Cause Indeterminate.Established Appropriate Compensatory Actions for Fire Barriers.With 981001 Ltr ML18106A8951998-09-28028 September 1998 LER 98-012-01:on 980725,noted That Afs Was Operated with Less than Required Number of Operable AFW Pumps.Caused by Improper Procedure Implementation.Runout Protection Pressure Device for 22 AFW Pumps Was Returned to Svc.With 980928 Ltr ML18106A8821998-09-21021 September 1998 LER 98-013-00:on 980820,noted Surveillance of Containment Penetration Overcurrent Protection Devices Missed.Caused by Human Error.Satisfactorily Tested Apprpriate Breakers & Disciplined Involved Personnel.With 980921 Ltr ML18106A8791998-09-16016 September 1998 LER 96-006-01:on 960717,determined That non-radioactive Liquid Basin Radwaste Monitor Inoperable During Low Head Conditions.Caused by Inadequate Design Change Package.Design Change 1EC3663-01 Has Been Installed.With 980916 Ltr ML18106A8801998-09-0808 September 1998 LER 98-013-00:on 980806,operation with TS Required Equipment OOS Was Noted.Caused by Human Error.Reviewed Processes & Practices Re Safety Sys Status Control,Procedure Rev & Extra Training.With 980908 Ltr ML18106A8531998-08-27027 August 1998 LER 98-007-00:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Cause of Event Has Not Yet Been Determined.Assembled Root Cause Team & Replaced Affected tubing.W/980827 Ltr ML18106A8521998-08-27027 August 1998 LER 98-011-00:on 980803,ESFA During a 4KV Automatic Transfer Test Was Noted.Caused by Premature Release of Control Console Pushbutton Due to Inadequate Procedural Step.Revised procedure.W/980827 Ltr ML18106A8421998-08-24024 August 1998 LER 98-012-00:on 980725,discovered That Plant Had Operated in Modes 1 & 2 w/twenty-two AFW Pumps Inoperable.Caused by Failure to Restore Pump Runout Protection Pressure Device to Svc.Returned Subject Device to svc.W/980824 Ltr ML18106A8431998-08-24024 August 1998 LER 98-009-00:on 980810,failure to Post Continuous Firewatch as Required by Fire Protection Plan Noted.Caused by Failure to Recognize Concurrent Conditions.Continuous Firewatch Was Posted Immediately & Repaired Smoke detectors.W/980824 Ltr ML18106A8141998-08-13013 August 1998 LER 98-010-00:on 980714,determined That Leakage from Boron Injection Tank Exceeded Max Allowable ECCS Leakage from Sources Outside Containment.Caused by Leaking 2SJ404 Manual Sample valve.2SJ404 Valve repaired.W/980813 Ltr ML18106A8201998-08-13013 August 1998 LER 98-012-00:on 980715,potential to Exceed Rating of Piping Due to Isolation of Overpressure Protection Line Was Noted. Caused by Inadequate Procedural Guidance.Appropriate Operations Dept Procedures Have Been revised.W/980813 Ltr ML18106A6931998-06-29029 June 1998 LER 98-003-00:on 980122,inappropriate Plugging of Tubes R9C60 & R10C60 in Salem Unit 2 Sg,Was Performed.Caused by Failure of Qualification,Verification & Validation Process. Tubes Reviewed to Verify No Others Inappropriately Plugged ML18106A6471998-06-0404 June 1998 LER 98-011-00:on 980505,improper Isolation of Single Cell Battery Charger from 125 Vdc Battery Was Noted.Caused by Inadequate 10CFR50.59 Applicability Review.Placed Procedure SC.MD-CM.ZZ-0024(Q) on Administrative hold.W/980604 Ltr ML18106A6421998-06-0101 June 1998 LER 98-010-00:on 931019,reactor Pressure Vessel Insp Plugs Were Out of Configuration,Was Noted.Caused by Personnel Error.Proper Configuration Was Restored Shortly After Discovery Prior to Entering Mode 2.W/980601 Ltr ML18106A6431998-05-29029 May 1998 LER 98-006-01:on 980227,determined Incorrect Scaling Error of First Stage Pressure Transmitter Existed.Caused by Human Error.Revised Setpoint Calculation SC-MS002-01 & Revised Associated Instrument Calibr Database info.W/980529 Ltr ML18106A6141998-05-18018 May 1998 LER 98-008-00:on 970814,failure to Test 21 & 22 AF 40 Valves in Closed Direction as Required by TS 4.0.5 Was Noted.Caused by Inadequate Design Mod Process.Motor Driven 21/22 AF 40 Valves Were Tested IAW Revised procedure.W/980518 Ltr ML18106A5901998-05-0101 May 1998 LER 98-009-00:on 980405,epoxy Missing from Terminals of H Analyzer Was Noted.Caused by Inadequate Development of Procedure.H Analyzers Were Repaired & Review of Other Safety Related Equipment in Containment Was performed.W/980501 Ltr ML18106A5611998-04-20020 April 1998 LER 98-008-00:on 980323,inadequate Testing of Salem Unit 1 Containment Air Locks Resulted in Entering TS 3.0.3.Caused by less-than-adequate Work Practices During Replacement of Equalizing Valve.Salem Unit 2 Airlocks Were Inspected ML18106A6061998-04-0101 April 1998 Corrected LER 98-004-00:on 980302,failure to Comply W/Tss 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Have Been Taken to Correctly Document Safety Factors.Corrects Prior Similar Occurrences ML18106A4451998-04-0101 April 1998 LER 98-004-00:on 980302,failure to Perform TS 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Were Taken to Correctly Document Safety factors.W/980401 Ltr ML18106A4351998-03-30030 March 1998 LER 98-006-00:on 980227,incorrect Scaling of First Stage Turbine Impulse Pressure Transmitters Noted.Cause Indeterminate.Implemented Procedure Changes & re-scaled Affected Turbine Impulse Pressure transmitters.W/980330 Ltr ML18106A3961998-03-20020 March 1998 LER 98-005-00:on 980219,inoperability of Twelve EDG Fuel Oil Transfer Pump (FOTP) Noted.Caused by Installation of Incorrect Control Switch.Installed Correct off-auto-manual Switch & Verified Operability of Twelve FOTP.W/980320 Ltr ML18106A5781998-03-20020 March 1998 Corrected LER 98-005-00:on 980219,inoperability of 12 Fuel Oil Transfer Pump (Fotp),Noted.Caused by Installation of Incorrect Control Switch.Field Insp Performed to Verify Configuration of Switches for 11,21 & 22 FOTPs ML18106A4021998-03-20020 March 1998 LER 98-007-00:on 980218,failure to Establish Containment Integrity (Closure) Prior to Fuel Movement Was Noted.Caused by Failure to Identify & Include Condensate Pot Vent in Appropriate Valve Lineup.Valves identified.W/980320 Ltr ML18106A4031998-03-20020 March 1998 LER 98-006-00:on 980221,ESF Actuation of 11 & 12 Auxiliary Feedwater Pumps Occurred.Caused by Human Error.Operators Promptly Established Feedwater to All SG & Restored Proper Water levels.W/980320 Ltr 1999-08-26
[Table view] Category:RO)
MONTHYEARML18107A5031999-08-26026 August 1999 LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr ML18107A4691999-07-28028 July 1999 LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr ML18107A4441999-07-0606 July 1999 LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr ML18107A4211999-07-0202 July 1999 LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr ML18107A4321999-07-0101 July 1999 LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr ML18107A4331999-07-0101 July 1999 LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr ML18107A3951999-06-17017 June 1999 LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr ML18107A3661999-06-0909 June 1999 LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr ML18107A3551999-06-0202 June 1999 LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr ML18107A3541999-06-0101 June 1999 LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr ML18107A2931999-05-12012 May 1999 LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr ML18107A2781999-05-10010 May 1999 LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr ML18107A2791999-05-0404 May 1999 LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr ML18107A2741999-05-0303 May 1999 LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr ML18107A2351999-04-23023 April 1999 LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr ML18106B1471999-03-29029 March 1999 LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr ML18106B0701999-02-16016 February 1999 LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr ML18106B0491999-01-28028 January 1999 LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr ML18106B0401999-01-18018 January 1999 LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr ML18106B0081998-12-24024 December 1998 LER 97-001-01:on 970215,failure to Perform TS Surveillance of Component Cooling Water Sys Check Valves Occurred.Caused by Inadequate Communication Between EOP Group & IST Reviewers.Procedure Revised.With 981224 Ltr ML18106B0021998-12-17017 December 1998 LER 98-015-01:on 980924,improper Installation of Test Equipment to RPS Occurred.Caused by Inadequate 10CFR50.59 Applicability Reviews During Past Revs.Revised Procedures. with 981217 Ltr ML18106A9551998-11-0303 November 1998 LER 96-013-01:on 960711,concluded That Current Gain & Bias Settings Had Rendered Overtemperature Delta Temp Protection Channels Inoperable.Caused by Scaling Error.Licensee Will Revise Scaling Calculations.With 981105 Ltr ML18106A9451998-10-30030 October 1998 LER 97-004-01:on 970408,failure to Comply with TS Action Statement,Dg Start & Inadequate Surveillance Testing,Was Noted.Caused by Inadequate Tracking of Inoperable Equipment. Discussed Event & Lessons Learned.With 981022 Ltr ML18106A9491998-10-22022 October 1998 LER 98-015-00:on 980924,identified Improper Installation of Test Equipment to Rps.Cause Indeterminate.Procedures for Installation of Test Equipment for Collection of State Point Data Were Placed on Administrative Hold.With 981022 Ltr ML18106A9301998-10-21021 October 1998 LER 98-014-00:on 980725,noted Improper Calibr of Liquid Radwaste Effluent Line Radiation Monitor.Caused by Inattention to Detail by Maint Personnel.Channel Calibr Was Successfully Performed on 1R18 on 980821.With 981019 Ltr ML18106A9071998-10-0101 October 1998 LER 98-014-00:on 980918,discovered That Fire Barrier Matl for HVAC Ducts Does Not Meet Required Level of Fire Resistance.Cause Indeterminate.Established Appropriate Compensatory Actions for Fire Barriers.With 981001 Ltr ML18106A8951998-09-28028 September 1998 LER 98-012-01:on 980725,noted That Afs Was Operated with Less than Required Number of Operable AFW Pumps.Caused by Improper Procedure Implementation.Runout Protection Pressure Device for 22 AFW Pumps Was Returned to Svc.With 980928 Ltr ML18106A8821998-09-21021 September 1998 LER 98-013-00:on 980820,noted Surveillance of Containment Penetration Overcurrent Protection Devices Missed.Caused by Human Error.Satisfactorily Tested Apprpriate Breakers & Disciplined Involved Personnel.With 980921 Ltr ML18106A8791998-09-16016 September 1998 LER 96-006-01:on 960717,determined That non-radioactive Liquid Basin Radwaste Monitor Inoperable During Low Head Conditions.Caused by Inadequate Design Change Package.Design Change 1EC3663-01 Has Been Installed.With 980916 Ltr ML18106A8801998-09-0808 September 1998 LER 98-013-00:on 980806,operation with TS Required Equipment OOS Was Noted.Caused by Human Error.Reviewed Processes & Practices Re Safety Sys Status Control,Procedure Rev & Extra Training.With 980908 Ltr ML18106A8531998-08-27027 August 1998 LER 98-007-00:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Cause of Event Has Not Yet Been Determined.Assembled Root Cause Team & Replaced Affected tubing.W/980827 Ltr ML18106A8521998-08-27027 August 1998 LER 98-011-00:on 980803,ESFA During a 4KV Automatic Transfer Test Was Noted.Caused by Premature Release of Control Console Pushbutton Due to Inadequate Procedural Step.Revised procedure.W/980827 Ltr ML18106A8421998-08-24024 August 1998 LER 98-012-00:on 980725,discovered That Plant Had Operated in Modes 1 & 2 w/twenty-two AFW Pumps Inoperable.Caused by Failure to Restore Pump Runout Protection Pressure Device to Svc.Returned Subject Device to svc.W/980824 Ltr ML18106A8431998-08-24024 August 1998 LER 98-009-00:on 980810,failure to Post Continuous Firewatch as Required by Fire Protection Plan Noted.Caused by Failure to Recognize Concurrent Conditions.Continuous Firewatch Was Posted Immediately & Repaired Smoke detectors.W/980824 Ltr ML18106A8141998-08-13013 August 1998 LER 98-010-00:on 980714,determined That Leakage from Boron Injection Tank Exceeded Max Allowable ECCS Leakage from Sources Outside Containment.Caused by Leaking 2SJ404 Manual Sample valve.2SJ404 Valve repaired.W/980813 Ltr ML18106A8201998-08-13013 August 1998 LER 98-012-00:on 980715,potential to Exceed Rating of Piping Due to Isolation of Overpressure Protection Line Was Noted. Caused by Inadequate Procedural Guidance.Appropriate Operations Dept Procedures Have Been revised.W/980813 Ltr ML18106A6931998-06-29029 June 1998 LER 98-003-00:on 980122,inappropriate Plugging of Tubes R9C60 & R10C60 in Salem Unit 2 Sg,Was Performed.Caused by Failure of Qualification,Verification & Validation Process. Tubes Reviewed to Verify No Others Inappropriately Plugged ML18106A6471998-06-0404 June 1998 LER 98-011-00:on 980505,improper Isolation of Single Cell Battery Charger from 125 Vdc Battery Was Noted.Caused by Inadequate 10CFR50.59 Applicability Review.Placed Procedure SC.MD-CM.ZZ-0024(Q) on Administrative hold.W/980604 Ltr ML18106A6421998-06-0101 June 1998 LER 98-010-00:on 931019,reactor Pressure Vessel Insp Plugs Were Out of Configuration,Was Noted.Caused by Personnel Error.Proper Configuration Was Restored Shortly After Discovery Prior to Entering Mode 2.W/980601 Ltr ML18106A6431998-05-29029 May 1998 LER 98-006-01:on 980227,determined Incorrect Scaling Error of First Stage Pressure Transmitter Existed.Caused by Human Error.Revised Setpoint Calculation SC-MS002-01 & Revised Associated Instrument Calibr Database info.W/980529 Ltr ML18106A6141998-05-18018 May 1998 LER 98-008-00:on 970814,failure to Test 21 & 22 AF 40 Valves in Closed Direction as Required by TS 4.0.5 Was Noted.Caused by Inadequate Design Mod Process.Motor Driven 21/22 AF 40 Valves Were Tested IAW Revised procedure.W/980518 Ltr ML18106A5901998-05-0101 May 1998 LER 98-009-00:on 980405,epoxy Missing from Terminals of H Analyzer Was Noted.Caused by Inadequate Development of Procedure.H Analyzers Were Repaired & Review of Other Safety Related Equipment in Containment Was performed.W/980501 Ltr ML18106A5611998-04-20020 April 1998 LER 98-008-00:on 980323,inadequate Testing of Salem Unit 1 Containment Air Locks Resulted in Entering TS 3.0.3.Caused by less-than-adequate Work Practices During Replacement of Equalizing Valve.Salem Unit 2 Airlocks Were Inspected ML18106A6061998-04-0101 April 1998 Corrected LER 98-004-00:on 980302,failure to Comply W/Tss 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Have Been Taken to Correctly Document Safety Factors.Corrects Prior Similar Occurrences ML18106A4451998-04-0101 April 1998 LER 98-004-00:on 980302,failure to Perform TS 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Were Taken to Correctly Document Safety factors.W/980401 Ltr ML18106A4351998-03-30030 March 1998 LER 98-006-00:on 980227,incorrect Scaling of First Stage Turbine Impulse Pressure Transmitters Noted.Cause Indeterminate.Implemented Procedure Changes & re-scaled Affected Turbine Impulse Pressure transmitters.W/980330 Ltr ML18106A3961998-03-20020 March 1998 LER 98-005-00:on 980219,inoperability of Twelve EDG Fuel Oil Transfer Pump (FOTP) Noted.Caused by Installation of Incorrect Control Switch.Installed Correct off-auto-manual Switch & Verified Operability of Twelve FOTP.W/980320 Ltr ML18106A5781998-03-20020 March 1998 Corrected LER 98-005-00:on 980219,inoperability of 12 Fuel Oil Transfer Pump (Fotp),Noted.Caused by Installation of Incorrect Control Switch.Field Insp Performed to Verify Configuration of Switches for 11,21 & 22 FOTPs ML18106A4021998-03-20020 March 1998 LER 98-007-00:on 980218,failure to Establish Containment Integrity (Closure) Prior to Fuel Movement Was Noted.Caused by Failure to Identify & Include Condensate Pot Vent in Appropriate Valve Lineup.Valves identified.W/980320 Ltr ML18106A4031998-03-20020 March 1998 LER 98-006-00:on 980221,ESF Actuation of 11 & 12 Auxiliary Feedwater Pumps Occurred.Caused by Human Error.Operators Promptly Established Feedwater to All SG & Restored Proper Water levels.W/980320 Ltr 1999-08-26
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20217A9931999-09-30030 September 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data ML18107A5581999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Salem,Unit 2.With 991014 Ltr ML18107A5571999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Salem,Unit 1.With 991014 Ltr ML18107A5301999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Salem,Unit 2.With 990913 Ltr ML18107A5311999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Salem,Unit 1.With 990913 ML18107A5031999-08-26026 August 1999 LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr ML18107A5201999-08-12012 August 1999 Rev 0 to Sgs Unit 2 ISI RFO Exam Results (S2RFO#9) Second Interval,Second Period, First Outage (96RF). ML18107A4811999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Salem,Unit 1.With 990813 Ltr ML18107A4821999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Salem,Unit 2.With 990813 Ltr ML18107A4691999-07-28028 July 1999 LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr ML18107A4441999-07-0606 July 1999 LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr ML18107A4211999-07-0202 July 1999 LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr ML18107A4331999-07-0101 July 1999 LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr ML18107A4321999-07-0101 July 1999 LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr ML18107A5211999-07-0101 July 1999 Rev 0 to Sgs Unit 2 ISI RFO Exam Results (S2RFO#10) Second Interval,Second Period,Second Outage (99RF). ML18107A4351999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Salem,Unit 1.With 990713 Ltr ML18107A4341999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Salem,Unit 2.With 990713 Ltr ML20196H8621999-06-30030 June 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept ML18107A3951999-06-17017 June 1999 LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr ML18107A3661999-06-0909 June 1999 LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr ML18107A3551999-06-0202 June 1999 LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr ML18107A3441999-06-0101 June 1999 Interim Part 21 Rept Re Premature Over Voltage Protection Actuation in Circuit Specific Application in Dc Power Supply.Testing & Evaluation Activities Will Be Completed on 990716 ML18107A3541999-06-0101 June 1999 LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr ML18107A3681999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Salem Generating Station,Unit 1.With 990611 Ltr ML18107A3721999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Salem Generating Station,Unit 2.With 990611 Ltr ML18107A2931999-05-12012 May 1999 LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr ML18107A2781999-05-10010 May 1999 LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr ML18107A2791999-05-0404 May 1999 LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr ML18107A2741999-05-0303 May 1999 LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr ML18107A3711999-04-30030 April 1999 Corrected Monthly Operating Rept for Apr 1999 for Salem Generating Station,Unit 1 ML18107A3151999-04-30030 April 1999 Submittal-Only Screening Review of Salem Generating Station Individual Plant Exam for External Events (Seismic Portion), Rev 1 ML18107A2991999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Salem Unit 1.With 990514 Ltr ML18107A2971999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Salem Unit 2.With 990514 Ltr ML18107A2351999-04-23023 April 1999 LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr ML18107A2881999-04-0707 April 1999 Rev 0 to NFS-0174, COLR for Salem Unit 2 Cycle 11. ML18107A1821999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Salem,Unit 1.With 990414 Ltr ML18107A1831999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Salem,Unit 2.With 990414 Ltr ML18106B1471999-03-29029 March 1999 LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr ML18106B1021999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Salem Unit 2.With 990315 Ltr ML18106B1011999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Salem Unit 1.With 990315 Ltr ML18106B0931999-02-25025 February 1999 Part 21 Rept Re Possible Defect in Swagelok Pipe Fitting Tee,Part Number SS-6-T.Caused by Crack Due to Improper Location of Heated Bar.Only One Part Out of 7396 Pieces in Forging Lot Was Found to Be Cracked.Affected Util,Notified ML18106B0701999-02-16016 February 1999 LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr ML18106B0551999-02-0101 February 1999 Part 21 Rept Re Possible Matl Defect in Swagelok Pipe Fitting Tee,Part Number SS-6-T.Defect Is Crack in Center of Forging.Analysis of Part Is Continuing & Further Details Will Be Provided IAW Ncr Timetables.Drawing of Part,Encl ML18106B0561999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Salem Generating Station,Unit 2.With 990212 Ltr ML18106B0571999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Salem Generating Station,Unit 1.With 990212 Ltr ML20205P1671999-01-31031 January 1999 a POST-PLUME Phase, Federal Participation Exercise ML18106B0441999-01-29029 January 1999 Part 21 Rept Re Possible Defect in Swagelok Pipe Fitting Tee Part Number SS-6-T.Caused by Crack in Center of Forging. Continuing Analysis of Part & Will Provide Details in Acoordance with NRC Timetables ML18106B0491999-01-28028 January 1999 LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr ML18106B0401999-01-18018 January 1999 LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr ML18106B0251998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Salem Unit 2.With 990115 Ltr 1999-09-30
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OPS~G e
- Public Service Electric and Gas Company P.O. Box 236. Hancocks Bridge, New Jersey 08038-0236 Nuclear Buslnes5 Unit DECl T SB LR-N980576 U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 LER 272/98-015-01 SALEM GENERATING STATION-UNIT 1 FACILITY OPERATING LICENSE NO. DPR-70 DOCKET NO. 50-272 Gentlemen:
This Supplemental Licensee Event Report entitled "Improper Installation of Test Equipment to the Reactor Protection System" is being submitted pursuant to the requirements of the Code of Federal Regulations 10CFR50.73(a)(2)(i)(B) and 1OCFR50.73(a)(2)(ii)(B).
Sincerely,
--
A. C. Bakken 111 General Manager -
Salem Operations Attachment BJT C Distribution LER File 3.7 9812310135 981217 PDR ADOCK 05000272 6 PDR The pcMer is in p.ir hands.
95-2168 REV. 6/94
NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 EXPIRES 06/30/2001 (6-19981 Estimated burden per response to comply with this mandaloly information collection request so hrs. Reported lessons learned are incorporated into the licensim,i process and fed back to induslly. Forward comments regarding LICENSEE EVENT REPORT (LER) burden estimate to the Records Management Branch (T-6 F3;] U.S.
Nuclear Regulaloly Commission, Washington, DC 2055S-0001, a 'to the Paperwork Reduction Project (31~104), Office of Management and (See reverse for required number of Budget, Washington, DC 20503. If an information collection does not display digits/characters f.or each block) a currently va~id OMB conb"ol number, the NRC may not conduct or sponsor, and a person 1s not required to respond to, the information collection.
FACILITY NAME (11 DOCKET NUMBER 121 PAGEl31 Salem Unit 1 05000272 1 OF 6 TrnEl41 Improper Installation of Test Equipment to the Reactor Protection System CVl:lllT nATC l!>I CD ..,, , . . n~n 11 :1 DCD "!AT n~,TS: 171 nTMS:A CAl"ll ITIS:li:: II ~Uni.,., .... , ...
MON DAY YEAR YEAR SEQUENTIAL REVISION MONTH DAY YEAR FACILITY NAME DOCKET NUMBER Salem Unit 2 05000311 09 24 98 98 015 01 12 17 98 FACILITY NAME DOCKET NUMBER OPERATIN Mode 1
-r> ,.. .
20.2201(bJ AS:PnAT '" "I DI ...... ,.,..,T Tn TL.IC Deni 20.2203(a)(2)(v) x ,..., 1n ..,.,.. 5*
- 50. 731all211il trh--*- ..... nr - - - -
- 50. 73(a)(2)(viiiJ POWER LEVEL 100 20.22031all 1 J 20.2203(a)(2)(i) 20.2203(a)(3)(i) 20.2203(a)(3J(iiJ x 50. 731all211iiJ
- 50. 73(a)(2Jliii)
- 50. 73(a)(2)(xJ 73.71 20.2203(a)(2)(iil 20.2203(a)(4J 50. 73(a)(2)(iv) OTHER 20.2203(a)(2)(iiil 50.36Ccll1 J 50. 73(a)(2J(v) Specify in Abstract below or in NRC Form 366A 20.2203(a)(2)(ivJ 50.36(c)(2) 50. 73(a)(2)(viil I r n ...T* ........ ,.. .. TL.I"'" I., .. /1.,,
NAME TELEPHONE NUMBER (Include Area Codel Brian J. Thomas, Licensing Engineer 609-339-2022
........ ~ i:i 'S: ""'c I IMC cnD CAl"U CAHl*nC 11\1 TUI., 11':1\
CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TO EPIX TO EPIX
!i::llDDI ~* RS:PnRT 11A\ EXPECTED MnMTU n.o.v VFAD
'YES (If yes, complete EXPECTED SUBMISSION DATE). Ix !No ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)
A review of the procedure for the connection of test equipment for collection of State Point data identified that test leads from the four channels of Reactor Control and Protection system were connected to switch boxes that had not been qualified to the same requirements as the Reactor Control and Protection system. Specifically, these switchboxes had not been evaluated to determine their capability to resist multiple channel failures, the most credible being a seismic event. The connections to the Reactor Control and Protectior:i system were from the non-isolated portion of the system and were not provided with isolation devices as described in the Salem Updated Final Safety Analysis Report (UFSAR). Based on this, the channels connected to the switchboxes should have been declared inoperable with the test equipment installed since a proper evaluation was not performed prior to installing the test equipment.
The cause is attributed to inadequate 1OCFR50.59 applicability reviews during past revisions and the original issuance of the State Point Data procedure due to inadequate program guidance regarding the applicability of 1OCFR50.59 to maintenance and test equipment. A contributing factor to this event is ineffective corrective actions from similar events. This event is reportable under 10CFR50.73(a)(2)(i)(B), any condition prohibited by the plant's Technical Specifications and 1OCFR~O 73(a)(2)(ii)(8) ~nv rnnrfitinn th~t w~s n11tsirf P. the cf P.sirm h~sis of the nl~nt NRC FORM 366 (6-1998)
\.j' NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (6-1998)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME (1) DOCKET (2) LER NUMBER (6) PAGE!3l NUMBER (2)
SALEM UNIT 1 05000272 YEAR l SEQUENTIAL NUMBER I REVISION
. NUMBER 2 OF 6 98 - 015 - 01 TEXT (If more space is required, use additional copies of NRC Form 366AJ (17)
PLANT AND SYSTEM IDENTIFICATION Westinghouse - Pressurized Water Reactor Reactor Control and Protection System {JC/-}*
- Energy Industry Identification System (EllS) codes and component function identifier codes appear as {SS/CCC}.
CONDITIONS PRIOR TO OCCURRENCE At the time of discovery, Salem Unit 1 and Unit 2 were in Mode 1.
DESCRIPTION OF OCCURRENCE A review of the procedure for the connection of test equipment for collection of State Point data identified that test leads from the four channels of Reactor Control and Protection system were connected to switch boxes that had not been qualified to the same requirements as the Reactor Control and Protection system. Specifically, these switchboxes had not been evaluated to determine their capability to resist multiple channel failures, the most credible being a seismic event. The connections to the Reactor Control and Protection system were from the non-isolated portion of the system and were not provided with isolation devices as described in the Salem Updated Final Safety Analysis Report (UFSAR). Specifically the UFSAR states that, "the design criterion used to assure*
electrical isolation is that no analog signal which is required for initiation of reactor protection or engineered safety feature actuation is allowed to leave a set of protection channels. Where protection signal intelligence is required for other than protection functions an isolation amplifier is used to transmit the intelligence." Based on this, the channels connected to the switchboxes should have been declared inoperable with the test equipment installed since a proper evaluation was not performed prior to installing the test equipment.
Based on the above, this event is reportable under 10CFR50.73(a)(2)(i)(B), any condition prohibited by the plant's Technical Specifications and 10CFR50.73(a)(2)(ii)(B), any condition that was outside the design basis of the plant.
NRC FORM 366A (6-1998)
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (6-1998)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME 111 DOCKET 121 LER NUMBER (6) PAGE (3)
NUMBER (21 I
SALEM UNIT 1 05000272 YEAR I SEQUENTIAL NUMBER REVISION NUMBER 3 OF 6 98 - 015 -- 01 TEXT (If more space is required, use additional copies of NRC Form 366AJ (17)
CAUSE OF OCCURRENCE The cause is attributed to inadequate 1OCFR50.59 applicability reviews during past revisions and the original issuance of the State Point Data procedure due to inadequate program guidance regarding the applicability of 1OCFR50.59 to maintenance and test equipment. A contributing factor to this event is ineffective corrective actions from similar events as outlined in the following section.
PRIOR SIMILAR OCCURRENCES A review of LERs for the past two years identified the following similar occurrences concerning the installation of Maintenance and Test Equipment (M&TE) to operable plant systems:
LER 272/97-013-00: "Failure to Meet Technical Specification 3.8.1.1 Action B." This event consisted of returning the 2A Emergency Diesel Generator (EOG) to operable status with the test equipment hooked up. Restoring the EOG to operable status with the test equipment installed had not been previously evaluated and was contrary to the operations procedure. This event was attributed to personnel error for intentionally leaving the test equipment in place when declaring the EOG operable contrary to the procedure requirement that directed the removal of the test equipment. A corrective action from the LER was to provide appropriate direction for the installation of temporary test in.strumentation into operable plant equipment. This corrective action assessed the pro~dure for control of temporary modifications and the maintenance department troubleshooting procedure and determined that adequate guidance was provided in these procedures to ensure that installation of M&TE on operable systems would be evaluated under the 10CFR50.59 process. This assessment also identified enhancements to centralize the guidance for evaluating the installation of M&TE into a single document, which has not been completed.
LER 311/97-014-00: "Manual Reactor Trip From 100% Power Following Loss of Both Operating Steam Generator Feed Pumps." A circuit card in the Westrac Data Acquisition System (DAS) failed causing feedwater header pressure to indicate approximately 150 psig below actual. The advanced digital feedwater control system (ADFCS) responded by increasing feedwater pump speed causing feedwater flow to increase to more than 120% of full flow value. This caused feedwater pump suction pressure .to drop leading to the automatic trip of both feedwater pumps. The cause of the event was attributed to the failure of the Westrac DAS circuit card. Although the 1OCFR50.59 evaluation that had been performed discussed the modification to install the ADFCS including design, installation and testing, the potential failure modes of the M&TE were not discussed. The corrective actions associated with this LER consisted of addressing the specific impact of the Westrac DAS on the AFDCS and the installation of M&TE during modification testing.
NRC FORM 366A (6-1998)
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (6-1998)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME 111 DOCKET 121 LER NUMBER 161 PAGE 131 NUMBER 121 SALEM UNIT 1 05000272 YEAR I SEQUENTIAL NUMBER IREVISION NUMBER 4 OF 6 98 - 015 -- 01 TEXT (If more space is required, use additional copies of NRC Form 366AJ 1171 PRIOR SIMILAR OCCURRENCES (conf d)
LER 311/98-001-00: "Failure to Meet Technical Specification 3.3.7 Table 3.3-11 Item 19- RVLIS.n The Reactor Vessel Level Instrumentation System (RVLIS) was considered operable with data system acquisition system (DAS) equipment connected to the system. The DAS instrumentation provided inadequate isolation between the non-safety related DAS and the RVLIS channels.
Therefore, the RVLIS could not be considered operable with the test equipment installed. The cause was attributed to the failure to identify that the initial 50.59 evaluation for the RVLIS procedure installation assumed that during performance of the procedure, RVLIS would be considered
. inoperable. The corrective actions associated with this LER provided additional guidance in procedure SC.SE-AP.ZZ-0002(0), "Conduct of Testing," to assess the impact of M&TE during infrequently performed tests.
LER 272198-011-00: "Improper Isolation of the Single Cell Battery Charger from the 125 VDC Battery." The charging of cell 47 of the 1A 125 VDC battery using the single cell battery charger was identified as having been accomplished without proper evaluation for the isolation of the battery charger from the Class-1E 125 VDC battery. Although the single cell battery charger was installed in accordance with an existing maintenance procedure, proper analysis was not performed in accordance with the requirements of 1OCFR50.59 to evaluate the electrical isolation between the single cell charger and the safety related battery. The corrective actions assoCiated with this LER were to revise the program guidance document for 1OCFR50.59 to include examples concerning the connection of temporary equipment to operable systems, to include this issue in 10CFR50.59 refresher training beginning in July 1998, and to review maintenance procedures to determine if other procedures allowed temporary equipment to be installed on operable systems and then perform a review to determine if the connection of the temporary equipment had been adequately evaluated for system operation. The revision to the 1OCFR50.59 program guidance document was completed in August 1998. The discussion of this LER was included in the 1OCFR50.59 refresher training cycle that began in July 1998. The review of maintenance procedures to determine other instances of connecting temporary equipment was completed in August 1998 and identified several procedures that connected temporary equipment to operable systems. However, the review to determine if the effect of the temporary equipment had been adequately evaluated has not been completed. As a result of the review of maintenance procedures, the procedure for the installation of test equipment for the collection of State Point Data had been identified as a procedure requiring further evaluation for system impact.
NRC FORM 366A (6-1998)
'/ NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (6-1998)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FA'CILITY NAME 111 DOCKET 121 LER NUMBER 161 PAGE 131 NUMBER 121 I
I SEQUENTIAL REVISION SALEM UNIT 1 05000272 YEAR NUMBER NUMBER 5 OF 6 98 - 015 -- 01 TEXT (If more space is required, use additional copies of NRC Form 366AJ 1171 PRIOR SIMILAR OCCURRENCES (cont'd)
Upon review of the LERs above and the associated corrective actions, the root cause investigation identified a lack of commitment to program implementation. Although events at Salem and in the industry indicated a need for the review of the usage of M&TE when connecting equipment to operable systems, a programmatic approach that would provide a consistent approach to personnel for assessing M&TE usage had not been developed.
Although corrective actions were identified in previous event investigations that may have prevented this event, the deferral of corrective actions in the corrective action program by closing activities to new tasks led to untimely implementation of corrective actions. The Corrective Action Program guidance regarding the closure of corrective actions did not prohibit the closure of an existing task to a new task, which provided a method of deferring implementation of an action without receiving the appropriate management approval. On October 15, 1998, revision 16 of procedure NC.NA-AP.ZZ-OQ06(Q), "Corrective Action Program," was issued which provided further guidance for the closure of one corrective action task (CRCA) to another CRCA.
SAFETY CONSEQUENCES AND IMPLICATIONS The affect of the actual test equipment configuration used during statepoint data collection was reviewed to assess the impact to Reactor Control and Protection system. The only plausible failure that was determined to have an affect on the Reactor Control and Protection channels was if instrument loops shorted together during a seismic event. Testing identified that if the positive signal of one loop shorted to the negative of the other loop, large spikes in voltage occurred. This caused the voltage in one instrument loop to drop while the voltage in the other loop increased. Therefore, the occurrence of a seismic event while the test equipment was installed may have had the ability to affect multiple channels of the Reactor Control and Protection system with the test equipment installed. Since no design basis seismic event has occurred at Salem Station,_ there were no safety consequences associated with this event.
NRC FORM 366A (6-1998)
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (6-19981 LICENSEE EVENT REPORT CLER)
TEXT CONTINUATION
- .FA'CILITY NAME (1) DOCKET 121 LER NUMBER (6) PAGEl31 NUMBER 121 SALEM UNIT 1 05000272 YEAR I SEQUENTIAL NUMBER IREVISION NUMBER .6 OF 6 98 - 015 -- 01 TEXT (If more space is required, use additional copies of NRC i=orm 366AJ (171 CORRECTIVE ACTIONS
- 1. The procedures for the installation of test equipment for the collection of State Point Data for Salem Units 1 and 2 were placed on administrative hold to prevent use of the procedure until resolution of the connection of the test equipment to the Reactor Control and Protection system is resolved.
- 2. As committed in LER 272/98-011-00, review of maintenance procedures has been performed to determine if other procedures allow temporary equipment to be installed on operable systems. As a result of this review, ten (10) procedures (in addition to the State Point Data procedures) were placed on hold to prevent their use until the assessment of the M&TE connection is completed.
Nine (9) of the procedures placed on hold have been reviewed for the M&TE applications (the Statepoint Data Procedures and one other procedure remain on hold). The assessment of the current method for connecting the M&TE as directed in these nine procedures revealed no problems.
- 3. On October 15, 1998, revision 16 of procedure NC.NA-AP.ZZ-0006(0), "Corrective Action Program," was issued which provided further guidance for the closure of one corrective action task (CRCA) to another CRCA.
- 4. As committed in LER 272198-011-00, the "1 OCFR50.59 Program Guidance" procedure was revised in August 1998 to include examples concerning the connection of temporary equipment to operable systems when performing 1OCFR50.59 reviews.
- 5. As committed in LER 272/98-011-00, the subject of connection of M&TE to operable system~ was included in the 1OCFR50.59 refresher training cycle starting in July 1998.
NRC FORM 366A (6-19981