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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17292B7421999-07-20020 July 1999 LER 99-001-00:on 990628,ESF Signal Closed All Eight MSIVs While Plant Was Shutdown.Caused by Failure of Relay RPS-RLY-K10D.Subject Relay Was Replaced & Tested on 990630. with 990720 Ltr ML17292B4451998-10-27027 October 1998 LER 98-012-01:on 980715,failure to Comply with Requirements of TS SR 3.8.4.7 Was Noted.Caused by Inadequate Work Practices.Training Session Was Held with Personnel.With 981027 Ltr ML17284A7561998-09-0303 September 1998 LER 98-013-00:on 980805,ESF Actuations Were Noted Due to Deenergization of Vital Electrical Bus SM-8.Caused by Inadequate Direction in Troubleshooting Plan.Will Conduct Training for Engineering Personnel.With 980903 Ltr ML17284A7571998-09-0202 September 1998 LER 98-014-00:on 980807,completion of TS 3.8.1.F Required Shutdown Due to Inoperability of EDG-2 Was Noted.Caused by Degraded Voltage Regulator for DG-2.Replaced Voltage Regulator & Associated Scrs.With 980902 Ltr ML17284A7551998-09-0202 September 1998 LER 98-015-00:on 980808,discovered Reactor Coolant Pressure Boundary Leak During Shutdown Conditions.Caused by Leakage from Socket Weld (Fwb 63) on Elbow Connection.Failed Piping Connection Was Replaced.With 980902 Ltr ML17284A7311998-08-17017 August 1998 LER 98-012-00:on 980716,determined That 24-month SR 3.8.4.7 Had Not Been Fulfilled within Specified Frequency.Caused by Inadequate Work Practices.License Requested & Received Enforcement Discretion Re Battery Svc test.W/980817 Ltr ML17284A7121998-07-23023 July 1998 LER 98-006-01:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of 10CFR50,App R Calculations for High Impedance Faults.Caused by Inadequate Work Practices.Implemented Procedural Changes ML17284A6951998-07-17017 July 1998 LER 98-011-00:on 980617,ECCS Pump Room Flooding Was Noted Due to FP Sys Pipe Break.Caused by Inadequate Design of FP Sys.Detailed Review of FP Sys Design Was Conducted. W/980717 Ltr ML17284A6961998-07-15015 July 1998 LER 98-010-00:on 980615,TS Required Shutdown Due to Inoperability of TIP Sys Isolation Valve Was Noted.Caused by Improper Installation of TIP Tubing.Reattached Affected Tubing & Inspected Other TIP tubing.W/980715 Ltr ML17284A6731998-07-0101 July 1998 LER 98-009-00:on 980606,nuclear Steam Supply Shutoff Sys Group 3 & 4 Isolations During Testing Was Noted.Caused by Procedural Deficiency.Counseled Individuals Involved in preparation.W/980701 Ltr ML17284A6651998-06-24024 June 1998 LER 98-007-00:on 980530,inadvertent Full Scram & Division 1 ECCS Injection Was Noted.Caused by Failure to Meet Mgt Work Practice Expectation When Encountering Deficient Procedure. Incident Review Board Convened to Review event.W/980624 Ltr ML17284A6641998-06-24024 June 1998 LER 98-008-00:on 980531,inadvertent Full Scram During RPV Leak Testing in Mode 4 Was Noted.Caused by Change in Mgt Techniques.Revised Procedures to Take Into Account Addl Water Head in Pressure Sensing lines.W/980624 Ltr ML17284A6631998-06-19019 June 1998 LER 98-006-00:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of App R Calculations for High Impedance Fault Analysis.Caused Indeterminate. Implemented Procedural Changes Involving Operator Action ML17284A6551998-06-0404 June 1998 LER 98-005-00:on 980506,potential for Failure of RHR Sys Valve to Close on Isolation Signal Was Noted.Caused by Design Deficiency.Caution Tag Was Placed on RHR-V-40 Control Switch to Inform Plant Operators of limitation.W/980604 Ltr ML17284A6421998-06-0101 June 1998 LER 98-004-00:on 980502,determined That Primary Containment Penetration Overcurrent Protection Does Not Meet Reg Guide 1.63 Requirements.Caused by Inadequate Design Changes. Installed Addl Fuse in RHR-MO-9 circuit.W/980601 Ltr ML17292B3281998-04-0909 April 1998 LER 98-002-00:on 980311,reactor Scram & Plant Transient Occurred,Due to Failed Closed Main Steam Isolation Valve. Caused by Loss of Pneumatic Actuating Supply Pressure. Problem Evaluation Request Written for Failure of MS-V-22D ML17292B3291998-04-0909 April 1998 LER 98-003-00:on 980311,WNP-2 Experienced SCRAM Signal as Result of Low Rpv.Caused by Less than post-SCRAM Operational Strategy for Resetting SCRAM Signal in Conditions.Changes in post-SCRAM Operational Strategy implemented.W/980409 Ltr ML17292B2661998-03-0404 March 1998 LER 98-001-00:on 980203,automatic Start of HPCS EDG Was Noted.Caused by Operator Error.Operations Crew Stabilized Plant at Approximately 75% Reactor Power & Investigation of Event Was initiated.W/980304 Ltr ML17292B1111997-11-10010 November 1997 LER 97-011-00:on 971010,HPCS Battery Charger Failed.Caused by Failure of a Phase Firing Control Circuit Board Due to Aging During 7 Yrs of Use.Hpcs Sys Was Immediately Declared inoperable.W/971110 Ltr ML17292B1151997-11-0707 November 1997 LER 97-010-00:on 970906,discovered That TS SR 3.4.5.1 for Identified Portion of RCS Total Leakage Would Not Be Able to Perform within Time Limits of SR 3.0.2.Caused by Inadequate Methods.Method of Meeting SR 3.4.5.1 Established ML17292B0641997-09-24024 September 1997 LER 97-004-01:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Indication of Entry Into Region a of power-to-flow Map.Caused by Inadequate Attention to Detail.Established Event Evaluation teams.W/970924 Ltr ML17292B0241997-08-18018 August 1997 LER 97-009-00:on 970717,discovered Error in Recently Performed Inservice Testing procedure,OSP-TIP/IST-R701. Caused by Procedure Inadequacy.Plant Procedure OSP/TIP/IST-R701 Will Be changed.W/970818 Ltr ML17292B0291997-08-15015 August 1997 LER 97-008-00:on 970716,wire Seal Used to Lock Containment Instrument Air Pressure Control valve,CIA-PCV-2B,found Not Intact.Cause of Misadjustment of CIA-PCV-2B Unknown.Event Will Be Communicated to Plant employees.W/970815 Ltr ML17292B0201997-08-15015 August 1997 LER 97-S01-00:on 970718,failure to Take Compensatory Measure for Inoperative Microwave Security Zone Occurred. Caused by Personnel Error.Training Will Be Conducted W/ Appropriate Members of Security force.W/970815 Ltr ML17292A9481997-07-23023 July 1997 LER 97-007-00:on 970611,voluntary Rept of Automatic Start of DG-1 & DG-2 Was Experienced.Caused by Undervoltage Condition on Electrical Busses SM-7 & SM-8.Circulating Water Pump CW-P-1C Control Switch Placed in pull-to-lock.W/970723 Ltr ML17292A9201997-06-26026 June 1997 LER 97-006-00:on 970527,non-performance of Surveillance Requirement 3.6.1.3.2 for Blind Fanges,Was Noted.Caused Because Misunderstanding of Intent of Specs.Added Five Structural Assemblies for SP.W/970626 Ltr ML17292A8331997-04-28028 April 1997 LER 97-004-00:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Entry Into Region a of power-to-flow Map Following Planned Trip of Single Mfp. Event Evaluation teams,established.W/970428 Ltr ML17292A8311997-04-28028 April 1997 LER 97-005-00:on 970327,valid Reactor Scram Signal Received Due to Low Water Level Condition During Preparations for SRV Testing.Caused by Risks & Consequences of Decisions Not Completely Identified.Restored Water level.W/970428 Ltr ML17292A8251997-04-21021 April 1997 LER 97-003-00:on 970320,notification of Noncompliance W/Ts as TS SRs for Response Time Testing Were Not Being Met for Specified Instrumentation in Rps,Pcis & Eccs.Requested Enforcement Discretion for One Time exemption.W/970421 Ltr ML17292A7431997-03-20020 March 1997 LER 97-002-00:on 970218,determined That Rod Block Monitor (RBM) Calibr Values Were Not Set IAW Tech Specs.Caused by Calibr Procedures Inadequacies.Revised & re-performed RBM Channel Calibr procedures.W/970330 Ltr ML17292A7401997-03-13013 March 1997 LER 97-001-00:on 970211,reactor Water Cleanup Sys Blowdown Flow Isolation Setpoint Was Slightly Above TS Allowable Valve Occurred Due to Calculation Error.Lds Fss LD-FS-15 LD-FS-16 Were Declared inoperable.W/970313 Ltr ML17292A6641997-01-22022 January 1997 LER 96-009-00:on 961220,miscalculation of Instantaneous Overcurrent Relay Settings Resulted in Inoperability of safety-related Equipment.Caused by Utilization of Inappropriate Design.Testing Was completed.W/970122 Ltr ML17292A6461997-01-0606 January 1997 LER 96-008-00:on 961205,failure to Comply with TS Action Requirement for Emergency Core Cooling Sys Actuation Instrumentation Occurred Due to Unidentified Inoperability Condition.Pmr initiated.W/970106 Ltr ML17292A6371996-12-19019 December 1996 LER 96-007-00:on 961122,electrical Breakers Were Not Seismically Qualified in Test/Disconnect Position.Circuit Breaker Mfg Did Not Consider Raced Out Breaker Position During Testing.Relocated Circuit breakers.W/961217 Ltr ML17292A4121996-08-0808 August 1996 LER 96-006-00:on 960709,average Power Range Monitor Rod Block Downscale Surveillance Not Performed Prior to Entry Into Mode 1.Caused by long-standing Misinterpretation of Requirements of Tss.Procedures revised.W/960808 Ltr ML17292A3801996-07-24024 July 1996 LER 96-004-00:on 960624,plant Was Manually Scrammed by Control Room Personnel Due to Reactor Water Level Transient Experienced During Testing of Digital Feedwater Sys.Caused by Programming Error.Sys Was corrected.W/960724 Ltr ML17292A3771996-07-24024 July 1996 LER 96-005-00:on 960624,determined Missed Surveillance Test Re Channel Check of Average Power Range Monitor.Caused by Inadequate Procedures.Revised Surveillance Procedure Re When APRM Checks Must Be performed.W/960724 Ltr ML17292A3641996-07-12012 July 1996 LER 96-003-00:on 960615,required Surveillance Test Not Performed When Required by TS 3.4.1.3.Caused by Inadequate Procedures.Implementing Surveillance Procedure & Reactor Plant Startup Procedures revised.W/960712 Ltr ML17292A3361996-06-20020 June 1996 LER 96-002-00:on 960504,critical Bus SM-8 Lost Power When Supply Breaker 3-8 Tripped.Caused by Personnel Error. Operators Counselled & Procedures revised.W/960620 Ltr ML17292A2861996-05-24024 May 1996 LER 96-001-00:on 960425,inadvertent ESF Actuations Occurred Due to Tripping of Temporary Power Supply to IN-3.Caused by Personnel Error.Operations Restored to IN-3 Loads & Reset ESF actuations.W/960524 Ltr ML17291B0891995-10-19019 October 1995 LER 95-011-00:on 950919,failed to Comply W/Ts SR for RCIC Sys Due to Analysis Deficiency That Resulted in Inadequate Surveillance Test Procedure.Surveillance Procedure Revised to Correct deficiency.W/951019 Ltr ML17291A9021995-07-0707 July 1995 LER 95-010-00:on 950609,HPCS DG Declared Inoperable Due to Discovery That TS Test Method Incomplete.Caused by Inadequate Testing Procedure.Test Procedure for HPCS DG Reviewed & Special Test Procedures written.W/950707 Ltr ML17291A9031995-07-0707 July 1995 LER 95-009-00:on 950607,inadvertent MSIV Closure Occurred During Surveillance Test Due to Poor Communication Between Test Team.Determined That MSIV Closure Not Valid Because Closure Not Triggered by Plant conditions.W/950707 Ltr ML17291A8501995-06-0808 June 1995 LER 95-006-01:on 950405,reactor Scram Occurred During Surveillance Testing Due to Protective Sys Relay Failure. Replaced Failed Relay Before Plant Startup ML17291A8101995-05-12012 May 1995 LER 95-008-00:on 940125,TS Wording Lead to Potential TS Violation.Caused by Lack of Clarity in Ts.Submitted Improved TS for Plant to Provide Addl clarity.W/950512 Ltr ML17291A7841995-05-0505 May 1995 LER 95-007-00:on 950222,emergency Diesel Start Occurred Due to Voltage Transient on BPA Grid.Confirmation Was Received at 17:51 H That Disturbance Had Originated in BPA Grid ML17291A7801995-05-0404 May 1995 LER 95-006-00:on 950405,main Turbine Trip Occurred During Performance of Surveillance Test Due to Protective Sys Relay Failed.Replaced Failed Relay Before Plant startup.W/950504 Ltr ML17291A7851995-05-0303 May 1995 LER 95-005-00:on 950222,inoperable IRM Had Been Relied Upon to Meet TS Requirements During Reactor Startup.Caused by Lack of Neutron Source to Test Instrumentation. Sys Knowledge Gained Will Be incorporated.W/950503 Ltr ML17291A7071995-03-25025 March 1995 LER 95-004-00:on 950226,malfunction in Main Turbine DEH Control Sys Caused All Four High Pressure Turbine Governor Valves to Rapidly Close.Caused by Blown Fuse.Suspected Faulty Circuit Card replaced.W/950325 Ltr ML17291A7011995-03-20020 March 1995 LER 95-002-00:on 950218,automatic Reactor Scram Occurred. Caused by Erroneous Positioning of Control During Performance of Scheduled Periodic Functional Test.Control repositioned.W/950320 Ltr 1999-07-20
[Table view] Category:RO)
MONTHYEARML17292B7421999-07-20020 July 1999 LER 99-001-00:on 990628,ESF Signal Closed All Eight MSIVs While Plant Was Shutdown.Caused by Failure of Relay RPS-RLY-K10D.Subject Relay Was Replaced & Tested on 990630. with 990720 Ltr ML17292B4451998-10-27027 October 1998 LER 98-012-01:on 980715,failure to Comply with Requirements of TS SR 3.8.4.7 Was Noted.Caused by Inadequate Work Practices.Training Session Was Held with Personnel.With 981027 Ltr ML17284A7561998-09-0303 September 1998 LER 98-013-00:on 980805,ESF Actuations Were Noted Due to Deenergization of Vital Electrical Bus SM-8.Caused by Inadequate Direction in Troubleshooting Plan.Will Conduct Training for Engineering Personnel.With 980903 Ltr ML17284A7571998-09-0202 September 1998 LER 98-014-00:on 980807,completion of TS 3.8.1.F Required Shutdown Due to Inoperability of EDG-2 Was Noted.Caused by Degraded Voltage Regulator for DG-2.Replaced Voltage Regulator & Associated Scrs.With 980902 Ltr ML17284A7551998-09-0202 September 1998 LER 98-015-00:on 980808,discovered Reactor Coolant Pressure Boundary Leak During Shutdown Conditions.Caused by Leakage from Socket Weld (Fwb 63) on Elbow Connection.Failed Piping Connection Was Replaced.With 980902 Ltr ML17284A7311998-08-17017 August 1998 LER 98-012-00:on 980716,determined That 24-month SR 3.8.4.7 Had Not Been Fulfilled within Specified Frequency.Caused by Inadequate Work Practices.License Requested & Received Enforcement Discretion Re Battery Svc test.W/980817 Ltr ML17284A7121998-07-23023 July 1998 LER 98-006-01:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of 10CFR50,App R Calculations for High Impedance Faults.Caused by Inadequate Work Practices.Implemented Procedural Changes ML17284A6951998-07-17017 July 1998 LER 98-011-00:on 980617,ECCS Pump Room Flooding Was Noted Due to FP Sys Pipe Break.Caused by Inadequate Design of FP Sys.Detailed Review of FP Sys Design Was Conducted. W/980717 Ltr ML17284A6961998-07-15015 July 1998 LER 98-010-00:on 980615,TS Required Shutdown Due to Inoperability of TIP Sys Isolation Valve Was Noted.Caused by Improper Installation of TIP Tubing.Reattached Affected Tubing & Inspected Other TIP tubing.W/980715 Ltr ML17284A6731998-07-0101 July 1998 LER 98-009-00:on 980606,nuclear Steam Supply Shutoff Sys Group 3 & 4 Isolations During Testing Was Noted.Caused by Procedural Deficiency.Counseled Individuals Involved in preparation.W/980701 Ltr ML17284A6651998-06-24024 June 1998 LER 98-007-00:on 980530,inadvertent Full Scram & Division 1 ECCS Injection Was Noted.Caused by Failure to Meet Mgt Work Practice Expectation When Encountering Deficient Procedure. Incident Review Board Convened to Review event.W/980624 Ltr ML17284A6641998-06-24024 June 1998 LER 98-008-00:on 980531,inadvertent Full Scram During RPV Leak Testing in Mode 4 Was Noted.Caused by Change in Mgt Techniques.Revised Procedures to Take Into Account Addl Water Head in Pressure Sensing lines.W/980624 Ltr ML17284A6631998-06-19019 June 1998 LER 98-006-00:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of App R Calculations for High Impedance Fault Analysis.Caused Indeterminate. Implemented Procedural Changes Involving Operator Action ML17284A6551998-06-0404 June 1998 LER 98-005-00:on 980506,potential for Failure of RHR Sys Valve to Close on Isolation Signal Was Noted.Caused by Design Deficiency.Caution Tag Was Placed on RHR-V-40 Control Switch to Inform Plant Operators of limitation.W/980604 Ltr ML17284A6421998-06-0101 June 1998 LER 98-004-00:on 980502,determined That Primary Containment Penetration Overcurrent Protection Does Not Meet Reg Guide 1.63 Requirements.Caused by Inadequate Design Changes. Installed Addl Fuse in RHR-MO-9 circuit.W/980601 Ltr ML17292B3281998-04-0909 April 1998 LER 98-002-00:on 980311,reactor Scram & Plant Transient Occurred,Due to Failed Closed Main Steam Isolation Valve. Caused by Loss of Pneumatic Actuating Supply Pressure. Problem Evaluation Request Written for Failure of MS-V-22D ML17292B3291998-04-0909 April 1998 LER 98-003-00:on 980311,WNP-2 Experienced SCRAM Signal as Result of Low Rpv.Caused by Less than post-SCRAM Operational Strategy for Resetting SCRAM Signal in Conditions.Changes in post-SCRAM Operational Strategy implemented.W/980409 Ltr ML17292B2661998-03-0404 March 1998 LER 98-001-00:on 980203,automatic Start of HPCS EDG Was Noted.Caused by Operator Error.Operations Crew Stabilized Plant at Approximately 75% Reactor Power & Investigation of Event Was initiated.W/980304 Ltr ML17292B1111997-11-10010 November 1997 LER 97-011-00:on 971010,HPCS Battery Charger Failed.Caused by Failure of a Phase Firing Control Circuit Board Due to Aging During 7 Yrs of Use.Hpcs Sys Was Immediately Declared inoperable.W/971110 Ltr ML17292B1151997-11-0707 November 1997 LER 97-010-00:on 970906,discovered That TS SR 3.4.5.1 for Identified Portion of RCS Total Leakage Would Not Be Able to Perform within Time Limits of SR 3.0.2.Caused by Inadequate Methods.Method of Meeting SR 3.4.5.1 Established ML17292B0641997-09-24024 September 1997 LER 97-004-01:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Indication of Entry Into Region a of power-to-flow Map.Caused by Inadequate Attention to Detail.Established Event Evaluation teams.W/970924 Ltr ML17292B0241997-08-18018 August 1997 LER 97-009-00:on 970717,discovered Error in Recently Performed Inservice Testing procedure,OSP-TIP/IST-R701. Caused by Procedure Inadequacy.Plant Procedure OSP/TIP/IST-R701 Will Be changed.W/970818 Ltr ML17292B0291997-08-15015 August 1997 LER 97-008-00:on 970716,wire Seal Used to Lock Containment Instrument Air Pressure Control valve,CIA-PCV-2B,found Not Intact.Cause of Misadjustment of CIA-PCV-2B Unknown.Event Will Be Communicated to Plant employees.W/970815 Ltr ML17292B0201997-08-15015 August 1997 LER 97-S01-00:on 970718,failure to Take Compensatory Measure for Inoperative Microwave Security Zone Occurred. Caused by Personnel Error.Training Will Be Conducted W/ Appropriate Members of Security force.W/970815 Ltr ML17292A9481997-07-23023 July 1997 LER 97-007-00:on 970611,voluntary Rept of Automatic Start of DG-1 & DG-2 Was Experienced.Caused by Undervoltage Condition on Electrical Busses SM-7 & SM-8.Circulating Water Pump CW-P-1C Control Switch Placed in pull-to-lock.W/970723 Ltr ML17292A9201997-06-26026 June 1997 LER 97-006-00:on 970527,non-performance of Surveillance Requirement 3.6.1.3.2 for Blind Fanges,Was Noted.Caused Because Misunderstanding of Intent of Specs.Added Five Structural Assemblies for SP.W/970626 Ltr ML17292A8331997-04-28028 April 1997 LER 97-004-00:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Entry Into Region a of power-to-flow Map Following Planned Trip of Single Mfp. Event Evaluation teams,established.W/970428 Ltr ML17292A8311997-04-28028 April 1997 LER 97-005-00:on 970327,valid Reactor Scram Signal Received Due to Low Water Level Condition During Preparations for SRV Testing.Caused by Risks & Consequences of Decisions Not Completely Identified.Restored Water level.W/970428 Ltr ML17292A8251997-04-21021 April 1997 LER 97-003-00:on 970320,notification of Noncompliance W/Ts as TS SRs for Response Time Testing Were Not Being Met for Specified Instrumentation in Rps,Pcis & Eccs.Requested Enforcement Discretion for One Time exemption.W/970421 Ltr ML17292A7431997-03-20020 March 1997 LER 97-002-00:on 970218,determined That Rod Block Monitor (RBM) Calibr Values Were Not Set IAW Tech Specs.Caused by Calibr Procedures Inadequacies.Revised & re-performed RBM Channel Calibr procedures.W/970330 Ltr ML17292A7401997-03-13013 March 1997 LER 97-001-00:on 970211,reactor Water Cleanup Sys Blowdown Flow Isolation Setpoint Was Slightly Above TS Allowable Valve Occurred Due to Calculation Error.Lds Fss LD-FS-15 LD-FS-16 Were Declared inoperable.W/970313 Ltr ML17292A6641997-01-22022 January 1997 LER 96-009-00:on 961220,miscalculation of Instantaneous Overcurrent Relay Settings Resulted in Inoperability of safety-related Equipment.Caused by Utilization of Inappropriate Design.Testing Was completed.W/970122 Ltr ML17292A6461997-01-0606 January 1997 LER 96-008-00:on 961205,failure to Comply with TS Action Requirement for Emergency Core Cooling Sys Actuation Instrumentation Occurred Due to Unidentified Inoperability Condition.Pmr initiated.W/970106 Ltr ML17292A6371996-12-19019 December 1996 LER 96-007-00:on 961122,electrical Breakers Were Not Seismically Qualified in Test/Disconnect Position.Circuit Breaker Mfg Did Not Consider Raced Out Breaker Position During Testing.Relocated Circuit breakers.W/961217 Ltr ML17292A4121996-08-0808 August 1996 LER 96-006-00:on 960709,average Power Range Monitor Rod Block Downscale Surveillance Not Performed Prior to Entry Into Mode 1.Caused by long-standing Misinterpretation of Requirements of Tss.Procedures revised.W/960808 Ltr ML17292A3801996-07-24024 July 1996 LER 96-004-00:on 960624,plant Was Manually Scrammed by Control Room Personnel Due to Reactor Water Level Transient Experienced During Testing of Digital Feedwater Sys.Caused by Programming Error.Sys Was corrected.W/960724 Ltr ML17292A3771996-07-24024 July 1996 LER 96-005-00:on 960624,determined Missed Surveillance Test Re Channel Check of Average Power Range Monitor.Caused by Inadequate Procedures.Revised Surveillance Procedure Re When APRM Checks Must Be performed.W/960724 Ltr ML17292A3641996-07-12012 July 1996 LER 96-003-00:on 960615,required Surveillance Test Not Performed When Required by TS 3.4.1.3.Caused by Inadequate Procedures.Implementing Surveillance Procedure & Reactor Plant Startup Procedures revised.W/960712 Ltr ML17292A3361996-06-20020 June 1996 LER 96-002-00:on 960504,critical Bus SM-8 Lost Power When Supply Breaker 3-8 Tripped.Caused by Personnel Error. Operators Counselled & Procedures revised.W/960620 Ltr ML17292A2861996-05-24024 May 1996 LER 96-001-00:on 960425,inadvertent ESF Actuations Occurred Due to Tripping of Temporary Power Supply to IN-3.Caused by Personnel Error.Operations Restored to IN-3 Loads & Reset ESF actuations.W/960524 Ltr ML17291B0891995-10-19019 October 1995 LER 95-011-00:on 950919,failed to Comply W/Ts SR for RCIC Sys Due to Analysis Deficiency That Resulted in Inadequate Surveillance Test Procedure.Surveillance Procedure Revised to Correct deficiency.W/951019 Ltr ML17291A9021995-07-0707 July 1995 LER 95-010-00:on 950609,HPCS DG Declared Inoperable Due to Discovery That TS Test Method Incomplete.Caused by Inadequate Testing Procedure.Test Procedure for HPCS DG Reviewed & Special Test Procedures written.W/950707 Ltr ML17291A9031995-07-0707 July 1995 LER 95-009-00:on 950607,inadvertent MSIV Closure Occurred During Surveillance Test Due to Poor Communication Between Test Team.Determined That MSIV Closure Not Valid Because Closure Not Triggered by Plant conditions.W/950707 Ltr ML17291A8501995-06-0808 June 1995 LER 95-006-01:on 950405,reactor Scram Occurred During Surveillance Testing Due to Protective Sys Relay Failure. Replaced Failed Relay Before Plant Startup ML17291A8101995-05-12012 May 1995 LER 95-008-00:on 940125,TS Wording Lead to Potential TS Violation.Caused by Lack of Clarity in Ts.Submitted Improved TS for Plant to Provide Addl clarity.W/950512 Ltr ML17291A7841995-05-0505 May 1995 LER 95-007-00:on 950222,emergency Diesel Start Occurred Due to Voltage Transient on BPA Grid.Confirmation Was Received at 17:51 H That Disturbance Had Originated in BPA Grid ML17291A7801995-05-0404 May 1995 LER 95-006-00:on 950405,main Turbine Trip Occurred During Performance of Surveillance Test Due to Protective Sys Relay Failed.Replaced Failed Relay Before Plant startup.W/950504 Ltr ML17291A7851995-05-0303 May 1995 LER 95-005-00:on 950222,inoperable IRM Had Been Relied Upon to Meet TS Requirements During Reactor Startup.Caused by Lack of Neutron Source to Test Instrumentation. Sys Knowledge Gained Will Be incorporated.W/950503 Ltr ML17291A7071995-03-25025 March 1995 LER 95-004-00:on 950226,malfunction in Main Turbine DEH Control Sys Caused All Four High Pressure Turbine Governor Valves to Rapidly Close.Caused by Blown Fuse.Suspected Faulty Circuit Card replaced.W/950325 Ltr ML17291A7011995-03-20020 March 1995 LER 95-002-00:on 950218,automatic Reactor Scram Occurred. Caused by Erroneous Positioning of Control During Performance of Scheduled Periodic Functional Test.Control repositioned.W/950320 Ltr 1999-07-20
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML17284A9001999-10-31031 October 1999 Rev 0 to COLR 99-15, WNP-2 Cycle 15,COLR GO2-99-177, LER 99-S01-00:on 990903,failure to Take Compensatory Measure within Required Time Upon Failure of Isolation Zone Microwave Unit,Was Noted.Caused by Personnel Error.Provided Refresher Training on Compensatory Measures.With1999-10-0101 October 1999 LER 99-S01-00:on 990903,failure to Take Compensatory Measure within Required Time Upon Failure of Isolation Zone Microwave Unit,Was Noted.Caused by Personnel Error.Provided Refresher Training on Compensatory Measures.With ML17284A8941999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for WNP-2.With 991012 Ltr ML17284A8801999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for WNP-2.With 990910 Ltr ML17284A8691999-07-31031 July 1999 Monthly Operating Rept for July 1999 for WNP-2.With 990813 Ltr ML17292B7421999-07-20020 July 1999 LER 99-001-00:on 990628,ESF Signal Closed All Eight MSIVs While Plant Was Shutdown.Caused by Failure of Relay RPS-RLY-K10D.Subject Relay Was Replaced & Tested on 990630. with 990720 Ltr ML17292B7271999-06-30030 June 1999 Monthly Operating Rept for June 1999 for WNP-2.With 990707 Ltr ML17292B6961999-05-31031 May 1999 Monthly Operating Repts for May 1999 for WNP-2.With 990608 Ltr ML17292B6641999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for WNP-2.With 990507 Ltr ML17292B6391999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for WNP-2.With 990413 Ltr ML17292B5871999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for WNP-2.With 990311 Ltr ML17292B5571999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for WNP-2.With 990210 Ltr ML17292B5621999-01-31031 January 1999 Rev 1 to COLR 98-14, WNP-2 Cycle 14 Colr. ML17292B5341999-01-15015 January 1999 Part 21 Rept Re Incorrect Modeling of BWR Lower Plenum Vol in Bison.Defect Applies Only to Reload Fuel Assemblies Currently in Operation at WNP-2.BISON Code Model for WNP-2 Has Been Revised to Correct Error ML17292B5331999-01-15015 January 1999 Part 21 Rept Re XL-S96 CPR Correlation for SVEA-96 Fuel. Defect Applies Only to WNP-2,during Cycles 12,13 & 14 Operation.Evaluations of Defect Performed by ABB-CE ML17292B4791998-12-31031 December 1998 Washington Public Power Supply Sys 1998 Annual Rept. with 981215 Ltr ML17292B5351998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for WNP-2.With 990112 Ltr ML17292B5741998-12-31031 December 1998 WNP-2 1998 Annual Operating Rept. with 990225 Ltr ML17284A8231998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for WNP-2.With 981207 Ltr ML17284A8081998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for WNP-2.With 981110 Ltr ML17292B4451998-10-27027 October 1998 LER 98-012-01:on 980715,failure to Comply with Requirements of TS SR 3.8.4.7 Was Noted.Caused by Inadequate Work Practices.Training Session Was Held with Personnel.With 981027 Ltr ML17284A7831998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for WNP-2.With 981007 Ltr ML17284A7491998-09-10010 September 1998 WNP-2 Inservice Insp Summary Rept for Refueling Outage RF13 Spring,1998. ML17284A7561998-09-0303 September 1998 LER 98-013-00:on 980805,ESF Actuations Were Noted Due to Deenergization of Vital Electrical Bus SM-8.Caused by Inadequate Direction in Troubleshooting Plan.Will Conduct Training for Engineering Personnel.With 980903 Ltr ML17284A7571998-09-0202 September 1998 LER 98-014-00:on 980807,completion of TS 3.8.1.F Required Shutdown Due to Inoperability of EDG-2 Was Noted.Caused by Degraded Voltage Regulator for DG-2.Replaced Voltage Regulator & Associated Scrs.With 980902 Ltr ML17284A7551998-09-0202 September 1998 LER 98-015-00:on 980808,discovered Reactor Coolant Pressure Boundary Leak During Shutdown Conditions.Caused by Leakage from Socket Weld (Fwb 63) on Elbow Connection.Failed Piping Connection Was Replaced.With 980902 Ltr ML17284A7681998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for WNP-2.With 980915 Ltr ML17284A7311998-08-17017 August 1998 LER 98-012-00:on 980716,determined That 24-month SR 3.8.4.7 Had Not Been Fulfilled within Specified Frequency.Caused by Inadequate Work Practices.License Requested & Received Enforcement Discretion Re Battery Svc test.W/980817 Ltr ML17284A7261998-07-31031 July 1998 Monthly Operating Rept for July 1998 for WNP-2.W/980810 Ltr ML17284A7121998-07-23023 July 1998 LER 98-006-01:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of 10CFR50,App R Calculations for High Impedance Faults.Caused by Inadequate Work Practices.Implemented Procedural Changes ML17284A6951998-07-17017 July 1998 LER 98-011-00:on 980617,ECCS Pump Room Flooding Was Noted Due to FP Sys Pipe Break.Caused by Inadequate Design of FP Sys.Detailed Review of FP Sys Design Was Conducted. W/980717 Ltr ML17284A6961998-07-15015 July 1998 LER 98-010-00:on 980615,TS Required Shutdown Due to Inoperability of TIP Sys Isolation Valve Was Noted.Caused by Improper Installation of TIP Tubing.Reattached Affected Tubing & Inspected Other TIP tubing.W/980715 Ltr ML17284A6731998-07-0101 July 1998 LER 98-009-00:on 980606,nuclear Steam Supply Shutoff Sys Group 3 & 4 Isolations During Testing Was Noted.Caused by Procedural Deficiency.Counseled Individuals Involved in preparation.W/980701 Ltr ML17284A6751998-06-30030 June 1998 Ro:On 980617,flooding of RB Northeast Stairwell with Consequential Flooding of Two ECCS Pump Rooms.Caused by Inadequate Fire Protection Sys Design.Pumped Out Water from Affected Areas to Point Below Berm Areas of Pump Rooms ML17284A6641998-06-24024 June 1998 LER 98-008-00:on 980531,inadvertent Full Scram During RPV Leak Testing in Mode 4 Was Noted.Caused by Change in Mgt Techniques.Revised Procedures to Take Into Account Addl Water Head in Pressure Sensing lines.W/980624 Ltr ML17284A6651998-06-24024 June 1998 LER 98-007-00:on 980530,inadvertent Full Scram & Division 1 ECCS Injection Was Noted.Caused by Failure to Meet Mgt Work Practice Expectation When Encountering Deficient Procedure. Incident Review Board Convened to Review event.W/980624 Ltr ML17284A6631998-06-19019 June 1998 LER 98-006-00:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of App R Calculations for High Impedance Fault Analysis.Caused Indeterminate. Implemented Procedural Changes Involving Operator Action ML17284A6551998-06-0404 June 1998 LER 98-005-00:on 980506,potential for Failure of RHR Sys Valve to Close on Isolation Signal Was Noted.Caused by Design Deficiency.Caution Tag Was Placed on RHR-V-40 Control Switch to Inform Plant Operators of limitation.W/980604 Ltr ML17284A6421998-06-0101 June 1998 LER 98-004-00:on 980502,determined That Primary Containment Penetration Overcurrent Protection Does Not Meet Reg Guide 1.63 Requirements.Caused by Inadequate Design Changes. Installed Addl Fuse in RHR-MO-9 circuit.W/980601 Ltr ML17284A6491998-05-31031 May 1998 Rev 0 to COLR 98-14, WNP-2,Cycle 14 Colr. ML17292B4031998-05-31031 May 1998 Monthly Operating Rept for May 1998 for WNP-2.W/980608 Ltr ML17292B3921998-04-30030 April 1998 Monthly Operating Rept for Apr 1998 for WNP-2.W/980513 Ltr ML17292B3291998-04-0909 April 1998 LER 98-003-00:on 980311,WNP-2 Experienced SCRAM Signal as Result of Low Rpv.Caused by Less than post-SCRAM Operational Strategy for Resetting SCRAM Signal in Conditions.Changes in post-SCRAM Operational Strategy implemented.W/980409 Ltr ML17292B3281998-04-0909 April 1998 LER 98-002-00:on 980311,reactor Scram & Plant Transient Occurred,Due to Failed Closed Main Steam Isolation Valve. Caused by Loss of Pneumatic Actuating Supply Pressure. Problem Evaluation Request Written for Failure of MS-V-22D ML17292B3371998-03-31031 March 1998 Monthly Operating Rept for Mar 1998 for WNP-2.W/980409 Ltr ML17292B2641998-03-0404 March 1998 Performance Self Assessment,WNP-2. ML17292B2661998-03-0404 March 1998 LER 98-001-00:on 980203,automatic Start of HPCS EDG Was Noted.Caused by Operator Error.Operations Crew Stabilized Plant at Approximately 75% Reactor Power & Investigation of Event Was initiated.W/980304 Ltr ML17292B2911998-02-28028 February 1998 Monthly Operating Rept for Feb 1998 for WNP-2.W/980313 Ltr ML17284A7971998-02-17017 February 1998 Rev 28 to Operational QA Program Description, WPPSS-QA-004.With Proposed Rev 29 ML17292B3591998-02-12012 February 1998 WNP-2 Cycle 14 Reload Design Rept. 1999-09-30
[Table view] |
Text
ACCELERATE DOCKV4ENT DISTRIJTION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
I ACCESSION NBR:9404070150 DOC.DATE: 94/03/31 NOTARXZED: NO DOCKET FACIL:50-397 WPPSS Nuclear Project. Unit 2. Washington Public Powe 05000397 R
AUTH. NAME AUTHOR AFFILIATION MACKMAN,C.D. Washington Public Power Supply System PARRISH,J.V. Washington Public Power Supply System RECIP.NAME RECIPXENT AFFILIATION D
SUBJECT:
LER 94-001-00:on 931230,untested fuel transfer to EDG fuel oil storage tanks occurredd.Caused by inadequate design change documentation & operating procedure. Procedures revised.W/940331 ltr.
DISTRIBUTION CODE: IE22T COPIES RECEXVED:LTR ENCL SIZE:
TITLE: 50.73/50.9 Licensee Event Report (LER), ncident Rpt, etc.
NOTES:
D RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL D
PDIV PD 1 1 CLIFFORD(J ~ 1 1 XNTERNAL: ACRS 1 '1 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DS P 2 2 NRR/DE/EELB 1 1 NRR/DE/EME B 1 1 NRR/DORS/OEAB 1
'
NRR/DRCH/HHFB 1 1 NRR/DRCH/HXCB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRXL/RPEB 1 1 NRR/DRSS/PRPB 2 2
/DSS4/SPLB 1 1 NRR/DSSA/SRXB 1 1 G VILE~ 02 1 1 RES/DSIR/EIB' 1. 1 RGN4 FILE 01 1 1 EXTERNAL: EG&G BRYCE,J.H 2 2 ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY,G.A 1 1 NSIC POORE,W. 1 1 NUDOCS FULL TXT 1 1 D
S D
NOTE TO ALL"RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE( CONTACI'HE DOCUMENT CONTROL DESK, ROOM Pi-37 (EXT. 504-2065) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DONT NEEDf FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES'REQUIRED: LTTR 28 ENCL 28
WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968 ~ 3000 George Washington Way ~ Richland, Washington 99352 March 31, 1994 G02-94-076 Docket No. 50-397 Document Control Desk U.S. Nuclear Regulatory Commission Washington, D.C. 20555
Subject:
NUCLEAR PLANT %NP-2, OPERATING LICENSE NPF-21 LICENSEE EVENT REPORT NO.94-001 Transmitted herewith is Licensee Event Report No.94-001 for WNP-2. This report is submitted in response to the report 'requirements of 10CFR50.73 and discusses the items of reportability, corrective action taken, and action taken to preclude recurrence.
/
Should you have any questions or desire additional information, please call me or Herbert E. Kook at {509) 377-4278.
Sincerely, J' Parrish {Mail Drop 1023) sistant Managing'Director, Operations JVP/CDM/jcs Enclosure CC: Mr. K. E. Perkins, Jr., NRC - Region V Mr. R. Barr, NRC Resident Inspector (Mail Drop 927N, 2 Copies)
Mr. N. -S. Reynolds, Winston & Strawn INPO Records Center - Atlanta, GA Mr. D. L. Williams, BPA (Mail Drop 399) 9404070150 940331 PDR ADOCK 05000397 8, PDR p
LICENSEE EVENT REPORT {LER)
AGILITY NAHE (I) DOCKET NUHB R ( ) PAGE (3)
Mashin ton Nuclear Plant - Unit 2 0 5 D 0 0 3 9 7 1 OF 6 ITLE (4)
UNTESTED FUEL TRANSFERRED TO THE EMERGENCY DIESEL GENERATOR FUEL OIL STORAGE TANKS EVENT DATE 5) LER NUHBER 6) REPORT DATE 7 OTHER FACILITIES INVOLVED 8}
HOHTH DAY YEAR YEAR , SEQUENTIAL EVI SION HONTH DAY YEAR FACILITY HAHES CKE NUH R (5)
,.; NUHBER UHBER 50 00 1 2 3 0 9 3 9 4 0 0 1 0 0 0 3 3 I 9 4 5 D 00 PERATING HIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREHEHTS OF 10 CFR 5: {Check one or more of the following) (ll ODE {9) 1 OVER LEVEL 0.402(b) 0.405{C) 50.73(a)(2)(iv} 77.71(b)
(io) 0.405(a)(1)(i) 50.36(c)(1) 50.73{a){2)(v) 73.73(c) 0.405(a}(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) THER {Specify in Abstract 0.405{a)(1)(iii) X 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) elow and in Text, HRC 0.405(a)(1)(iv) 50.73{a)(2)(ii) 50.73(a)(2)(viii)(B) orm 366A) o 405(a)(1)(v) 50.73(a)(2)(iii) 50.73{a)(2)(x)
LICENSEE CONTACT FOR THIS LER (12 NAHE TELEPHONE HUHBER C. D. Mackaman, Licensing Engineer REA CODE 0 9 7 7 4 4 5 1 COHPLETE ONE LINE FOR EACH COHPONENT FAILURE DESCRlBED IN THlS REPORT (13)
CAUSE SYSTEH COHPONENT HAHUFACTURER EPORTABLE CAUSE SYSTEH COHPONENT HANUFACTURER EPORTABLE 0 HPRDS TO HPRDS SUPPLEKENTAL REPORT EXPECTED (14) XPECTED SUBHlSSlOH HONTN OAY TEAR ATE (15)
YES (lf yes, coaplete EXPECTED SUBHISSIOH DATE) HO During the period from December 14 through December 21, 1993, diesel fuel that included untested fuel was transferred from the Auxiliary Boiler Fuel Oil Storage Tank (FO-TK-1) to each of the three Emergency Diesel Generator (EDG) Fuel Oil Storage Tanks (DO-TK-1A, DO-TK-1B, and DO-TK-2).
This event occurred during post modification testing of the recently installed Fuel Oil Filter Polisher System. Plant personnel involved in the testing identified the problem and initiated a Problem Evaluation Request (PER 293-1438) on December 30, 1993. An operability assessment was performed on December 30, 1993 to determine the status of EDG operability. All three EDGs (DG-1, DG-2, and DG-3) were determined to be operable. This event was inconsistent with Technical Specification Surveillance (TSS) Requirement 4.8.1.1.2.c, which requires that diesel fuel be sampled prior to addition to the EDG storage tanks.
As an immediate corrective action, personnel clearance tagged the Auxiliary Boiler suction valve for the Fuel Oil Filter Polisher System to assure the valve remains closed. This will prevent further transfer of fuel from the Auxiliary Boiler storage tank to the EDG storage tanks until a design review and Safety Evaluation are completed. In addition, fuel oil samples were taken from all four fuel oil storage tanks and sent to an independent chemical testing facility for analysis.
The root causes for this event were: (1) that the nonsafety-related Fuel Oil Filter Polisher System design change documentation did not include a 10CFR50.59 Safety Evaluation or an adequate evaluation of the nonsafety-related to safety-related system interactions, and (2) Operating Procedure PPM 2.8.15, "Diesel Fuel Oil Filter/Polisher System," did not include procedural controls to assure that TSS 4.8.1.1.2.c fuel cleanliness and testing requirements were satisfied during system operation.
LICENSEE EYENT REPOR C (LER)
TEXT CONTINUATION ACILTTT NAHE (1) OOCKET KUHBER (2) LER KUHBER (8) AGE (3) ear umber ev. No.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 4 01 0 2 F 6 ITLE (4)
UNTESTED FUEL TRANSFERRED TO THE EMERGENCY DIESEL GENERATOR FUEL OIL STORAGE TANKS Further corrective actions include: {1) performing a design review and Safety Evaluation for the Fuel Oil Filter Polisher System modification request (PMR 83-107), {2) changing appropriate plant procedures based on the design review and Safety Evaluation, (3) counseling and training on the'lessons learned from this event, and (4) performing design reviews for planned design changes that add or change inter-ties between safety-related and nonsafety-related systems.
This event posed no threat to the health and safety of the public or plant personnel.
RIICh i m Power Level - 100%
Plant Mode - 1 (Power Operation) vent D ri ti n In August 1993, approximately 17,000 gallons of untested diesel fuel oil was added to the Auxiliary Boiler storage tank. During the period from December 14 through December 21, 1993, diesel fuel that included the untested fuel was transferred from the Auxiliary Boiler Fuel Oil Storage Tank (FO-TK-1) to each of the three Emergency Diesel Generator (EDG) Fuel Oil Storage Tanks {DO-TK-1A, DO-TK-IB, and DO-TK-2). This event occurred during post modification testing of the recently installed Fuel Oil Filter Polisher System. The testing included demonstrating the capability to transfer fuel from the Auxiliary Boiler storage tank to an EDG storage tank, and to recirculate the fuel through the filter polisher and back to the Auxiliary Boiler tank. A Maintenance Work Request (MWR-AR6637) was used to perform the testing and included steps that recirculated approximately 5,000 gallons of the untested fuel from the Auxiliary Boiler storage tank through each EDG storage tank. Plant personnel involved in the testing identified the problem and initiated a Problem Evaluation Request (PER 293-1438) on December 30, 1993.
The System Engineer performed an operability assessment on December 30, 1993 to determine the status of EDG operability. All three EDGs (DG-1, DG-2, and DG-3) were determined to be operable during the period from December 14 through December 30, 1993 {the period in question). This determination was based on confidence that the untested fuel transferred from the Auxiliary Boiler tank met the American Society for Testing and Materials (ASTM) requirements specified in Technical Specifications 4.8.1.1.2.c and d. Analyses of fuel oil samples taken from all four fuel oil storage tanks supported this operability assessment.
mm i rr iv ion
- 1. Operations personnel clearance tagged the Auxiliary Boiler suction valve for the Fuel Oil Filter Polisher System to assure the valve remains closed. This will prevent further transfer of fuel from the Auxiliary Boiler storage tank to the EDG storage tanks until a design review and Safety Evaluation are completed.
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION AC1L17Y NAME (1) OOCKE7 NUMBER (2) LER NUMBER (B) AGE (3) ear umber ev. No.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 4 001 0 3 t' 17LE (4)
UNTESTED FUEL TRANSFERRED TO THE EMERGENCY DIESEL GENERATOR FUEL OIL STORAGE TANKS
- 2. Fuel oil samples were taken from all four fuel oil storage tanks and sent to Herguth Laboratories, Inc., an independent chemical testing facility, for analysis to assure compliance with the fuel quality requirements of TSS Requirement 4.8,1.1.2.c.
rtherEv1 ai n nd rr iveA i n 1 H I
The Supply System initially determined that this event was not reportable to the NRC based on a determination of no impact on EDG operability or fuel quality. However, after further evaluation, the original reportability determination was amended to recognize the noncompliance with TSS Requirement 4.8.1.1.2.c. Specifically, this event is being reported pursuant to 10CFR50.73(a)(2)(i)(B) as "Any operation or condition prohibited by the plant's Technical Specifications...."
- 2. A feature of the Fuel Oil Filter Polisher System design change was the capability of transferring fuel from the Auxiliary Boiler storage tank to the three EDG storage tanks. This was a significant change to the method of adding fuel to the EDG storage tanks and is controlled by TSS 4.8.1.1.2.c. However, the design change post modification testing =
instructions, the system operating procedure, and related surveillance procedures did not require the fuel in the Auxiliary Boiler storage tank to be sampled prior to transferring the fuel to the EDG storage tanks.
- 3. A design safety analysis for the Fuel Oil Filter Polisher System design change was completed on May 2, 1992. The preparer and reviewer did not recognize that the unit's operation could impact a safety-related system. Consequently, no Safety Evaluation was performed that would have evaluated the nonsafety-related to safety-related system interactions and identified the need for system controls.
- 4. The Plant Operating Committee (POC) reviewed the Fuel Oil Filter Polisher System design change on August 19, 1992 at POC Meeting 92-34 and again on August 26, 1992 at POC Meeting 92-35. POC members missed an opportunity to address the design change deficiencies because they were provided with inaccurate information based on an inadequate review of the design change documentation.
- 5. The Fuel Oil Filter Polisher System design change documentation included statements that identified Technical Specification fuel cleanliness requirements for system installation and that the Auxiliary Boiler storage tank will be connected to the EDG storage tanks. However, Operations Procedures personnel did not adequately review the design change documentation.
As a result, PPM 2.8.15, "Diesel Fuel Oil Filter/Polisher System," did not include procedural controls to assure that TSS 4.8.1.1.2.c fuel cleanliness and testing requirements were satisfied- during system operation.
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION AC1LlTT NAHE (1) OOCKET NUHBER (2) LER NUHBER (8) AGE (3) ear umber ev. No.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 4 01 0 4 F 6 lTLE (4)
UNTESTED FUEL TRANSFERRED To THE EHERGENCY DIESEL GENERATOR FUEL OIL STORAGE TANKS
- 6. The Fuel Oil Filter Polisher System design change testing was performed by MWR rather than by 'a special test procedure. This practice bypasses an opportunity for an additional 10CFR50.59 review and the higher level of scrutiny associated with approval of a Temporary Procedure in accordance with PPM 1.2.4, "Plant Procedure Approval Revision and Distribution.",
In this case, the design change post modification test used PPM 2.8.15 for system lineups and operation. However, a special test procedure should have been written and performed because the operating procedure was not adequate to support the post modification test.
Consequently, the Technical Specification requirements were not adequately addressed when the MWR post modification testing instructions directed the performer to transfer fuel from the Auxiliary Boiler storage tank to the EDG storage tanks.
- 7. As discussed above, Supply System personnel missed several opportunities to prevent this event. All of these missed opportunities were found to have, resulted from the mindset that "the fuel/polisher unit is not safety-related and [therefore] does not affect components or items that are safety-related," Action will be'taken to correct this mindset.
- 8. The Supply System believes that the changes incorporated into the 10CFR50.59 review and evaluation procedures on September 30, 1992 adequately address the related programmatic implications of this event.
- 9. =
The Supply System has improved the design change implementation review process since the Fuel Oil Filter Polisher System design change was reviewed and approved for installation.
Design changes are now reviewed by a Project Review Group (PRG) and Project Engineers have been given overall ownership of assigned design changes. They act as a single point of contact for coordinating activities and will follow issues associated with a design change through to resolution. These programmatic changes ensure that design changes receive a thorough pre-installation review and that implementation related issues are properly addressed.
gag /gee The root causes for this event were: (1) that the nonsafety-related Fuel Oil Filter Polisher System design change documentation did not include a 10CFR50.59 Safety Evaluation or an adequate evaluation of the nonsafety-related to safety-related system interactions, and (2) Operating Procedure PPM 2.8.15 did not include procedural controls to assure that TSS 4.8.1.1.2.c fuel cleanliness and testing requirements were satisfied during system operation.
A contributing cause was that a special test procedure was not written to perform the Fuel Oil Filter Polisher System design change post modification test.
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION ACILITY NAHE (1) OOCKET NUHBER (2) LER NUHBER (B) AGE (3)
"
ear umber ev. No.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 4 0 1 0 5 F 6 ITLE (4)
UNTESTED FUEL TRANSFERRED TO THE EMERGENCY DIESEL GENERATOR FUEL OIL STORAGE TANKS urth r rr iv A i n A design review and Safety Evaluation will be performed for the Fuel Oil Filter Polisher System design change Plant Modification Request (PMR 83-107) by August 1, 1994.
- 2. Surveillance Procedure PPMs 7.4.8.1.1,2, "Diesel Fuel Purification," 7.4.8.1.1.2.3A, "Diesel Generator New Fuel Test," and 7.4.8.1.1.2.3B, "Diesel Generator Storage Tank Fuel Test," will be reviewed and changed as necessary by September 1, 1994 based on the results of the Fuel Oil Filter Polisher System design review and Safety Evaluation.
- 3. Operating Procedure PPM 2.8;15 will be reviewed and changed as necessary by September 1, 1994 based on the results of the Fuel Oil Filter Polisher System design review and Safety Evaluation.
Training will be provided by April 30, 1994 for Design Engineers, Project Engineers, Technical Staff Engineers, and Operations procedure writers on the lessons learned from this event and the design issues relating to inter-ties and interactions between safety-related and nonsafety-related systems.
- 5. Design change packages that add or change inter-ties between safety-related and nonsafety-related systems, wh'ere the resulting interactions have not been previously evaluated, will be reviewed. Packages scheduled for implementation during the Spring 1994 Refueling Outage (R-9) will be reviewed by April 30, 1994. The scope of the remaining outstanding packages will be evaluated and a review schedule will be developed by July 31, 1994.
- 6. The individuals involved in this event, including POC members, will be counseled by April 30, 1994 on their role in causing the event and the lessons learned from the event.
- 7. A lessons learned memorandum will be sent to Licensing personnel by April 8, 1994 concerning the error in the initial reportability determination for this event and will be discussed with Licensing personnel by April 15, 1994.
f i nifi As previously discussed, an operability assessment established EDG operability during the period in question. Subsequent analyses of the fuel oil samples taken from all four fuel oil storage tanks supported this operability assessment. Based on this documentation, this event did not impact EDG operability or fuel quality. Accordingly, this event had no safety significance and posed no threat to the health and safety of the public or plant personnel.
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION ACILITY HAHE (1) OOCKET HUHBER (2) LER HUHBER (B) AGE (3) ear umber ev. Ho.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 4 0 I 0 6 F 6 ITLE (4)
UNTESTEO FUEL TRANSFERREO TO THE EMERGENCY DIESEL GENERATOR FUEL OIL STORAGE TANKS i ilrEvn LERs90-001, 90-007,90-015, and 90-027 reported diesel fuel oil sampling and analysis problems that resulted in Technical Specification noncompliance conditions. These previous events are similar because the fuel oil testing requirements were not met. However, the causes of these previous events did not involve design review or design implementation deficiencies. Thus, the corrective actions did not address the conditions described in this LER.
EIIS Inf rmation R f II R ferne
~tern /~mixen Auxiliary Boiler Fuel Oil SA TK Storage Tank (FO-TK-1)
Emergency Diesel Generator Fuel DC TK Oil Storage Tanks (DO-TK-1A, DO-TK-1B, and DO-TK-2)
Emergency Diesel Generators EK DG (DG-1, DG-2, and DG-3)
Fuel Oil Filter Polisher System DE FLT
r