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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
ACCEI.ERAT DOCUMENT DISTRIXUTiOX REGULATO~ INFORMATION DISTRIBUTION S~SiXM TEM (RXDS) i PCCEEEZON NBR:9301210231 DOC.DATE: 93/01/14 NOTARTZED: NO DOCKET t FACIL:50-397 WPPSS Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH. NAME AUTHOR AFFILIATION MACKAMAN,C. Washington Public Power Supply System BAKER,J.W. Washington Public Power Supply System RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
LER 92-046-00:on 921215,night technicians failed to collect main condenser offgas sample within TS time requirements, due to personnel error. Memo issued that will address D requirements for shift personnel.W/930114 ltr.
DISTRIBUTION CODE: XE22T COPIES RECEIVED:LTR ENCL SIZE:
TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.
NOTES:
RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL XD CODE/NAME LTTR ENCL D PD5 LA, 1 1 PD5 PD 1 1 CLIFFORDEJ 1 1 INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DET/EMEB 7E 1 1 NRR/DLPQ/LHFB10 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB 8D 1 1 NRR/DST/SICB8H3 1 1 NRR/DST/SPLB8D1 1 1 NRR/DST/SRXB 8E 1 1 g REG FXI4H 02 1 1 RES/DSIR/EIB 1 "1 RGN5 FXLE 01 1 1 EXTERNAL EGSrG BRYCE E J ~ H 2 2 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSXC MURPHY,G.A 1 1 NSIC POOREEW. 1 1 NUDOCS FULL TXT 1 1 D
D NOTE TO ALL"RIDS" RECIPIENTS'LEASE HELP US TO REDUCE WASTEI CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXI'. 504-2065) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEEDI FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 31 ENCL 31 po- 'i
(s WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968 ~ 3000 George Washington Way ~ Richland, Washington 99352 January 14, 1993 602-93-015 Docket No. 50-397 Document Control Desk U.S. Nuclear Regulatory Commission Washington, D.C. 20555
SUBJECT:
NUCLEAR PLANT WNP-2, OPERATING LICENSE NPF-21 LICENSEE EVENT REPORT NO.92-046 Transmitted herewith is Licensee Event Report No.92-046 for the WNP-2 Plant. 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.
Sincerely, J. W. Baker WNP-2 Plant Manager (Mail Drop 927M)
JWB/CD M/lr Enclosure CC: Mr. J. B. Martin, NRC - Region V Mr. R. Barr, NRC Resident Inspector (Mail Drop 901A, 2 Copies)
INPO Rcords Center - Atlanta, GA Mr. D. L. Williams, BPA (Mail Drop 399) gQQQg 6
'tt301210231 PDR ADOCK 930114 05000397
'33" S PDR
LICENSEE EVENOEPORT (LER)
FACILITY NAME (1) DOCKET NUMB R ( ) PAGE (3)
Washin ton Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 I OF TITLE (4)
FAILURE TO COLLECT AN OFFGAS SAMPLE WITHINTECHNICAL SPECIFICATION TIME REQUIREMENTS EVENT DATE 5) LER NUMBER 6 REPORT DATE (7) OTHER FACILITIES INVOLVED (8)
HONTH DAY YEAR YEAR SEQUENTIAL 5 EVI SION HONTH DAY YEAR FACILITY NAHES CKE NUHB R (5)
NUHBER <'.':i HUHBER 5 0 I 2 I 5 9 2 9 2 0 4 6 0 0 0 1 1 4 9 3 050 PERATING HIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREHENTS OF 10 CFR II: (Check one or more of the following) (li)
ODE (9) X POWER LEVEL 20.402(b) 20.405(C) 50.73(a)(2)(iv) 77.71(b)
(iO) 20.405(a)(1)(i} 50.36(c)(1) 50.73(a)(2)(v) 73.73(c) 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) THER (Specify in Abstract 20.405(a)(1)(iii) X 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) below and in Text, NRC 20.405(a)(1)(iv) 50.73(a)(2}(ii} 50.73(a)(2)(viii)(B) orm 366A) 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)
LICENSEE COHTACT FOR THIS LER 12
'lAHE TELEPHONE NUMBER REA CODE C. Mackaman, Compliance Engineer 5 0 9 7 7 - 4 4 5 1 COMPLETE OHE LINE FOR EACH COMPONENT'AILURE DESCRIBED IH THIS REPORT (13)
CAUSE SYSTEH COMPOHEHT MANUFACTURER EPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE 0 NPRDS TO HPRDS SUPPLEMENTAL REPORT EXPECTED (14) EXPECTED SUBMISSIOH MONTH DAY YEAR ATE (15)
YES (If yes, complete EXPECTED SUBMISSION DATE) NO TRACT TTTO On December 15, 1992, the night shift chemistry technicians failed to collect a main condenser offgas sample within the time required by Technical Specification 3.3.7. 12 and Table 3.3.7. 12-1 (Explosive Gas Monitoring Instrumentation). Contrary to the Technical Specifications eight hour requirement, a grab sample was not collected during the 11 hour1.273148e-4 days <br />0.00306 hours <br />1.818783e-5 weeks <br />4.1855e-6 months <br /> and 21 minute period between 1246 hours0.0144 days <br />0.346 hours <br />0.00206 weeks <br />4.74103e-4 months <br /> on December 15, 1992, and 0007 hours8.101852e-5 days <br />0.00194 hours <br />1.157407e-5 weeks <br />2.6635e-6 months <br /> on December 16, 1992.
No immediate corrective actions were required since the Technical Specification surveillance was current at the time of the event discovery.
The root cause was a work practice personnel error. A contributing cause was the ineffective implementation of chemistry department policies and practices.
This event posed no threat to the health and safety of either the public or plant personnel.
LICENSEE EVENT REPORT TEKI CONTlNUATlON (4)
"AGILITY NAHE (I) OOCKET NUHBER (2) LER NUHBER (6) AGE (3)
Year Number ev. No.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 2 046 00 2 F 6 jTLE (4)
FAILURE TO COLLECT AN OFFGAS SAMPLE WITHIN TECHNICAL SPECIFICATION TINE RE(UIREHENTS Plan ndition Power Level - 100%
Plant Mode - 1 (Power)
Event D cri tion On December 15, 1992, night shift chemistry technicians failed to collect a main condenser offgas sample within the time required by Technical Specification 3.3.7.12 and Table 3.3.7.12-1 (Explosive Gas Monitoring Instrumentation). Contrary to the Technical Specifications eight hour requirement, a grab sample was not collected during the 11 hour1.273148e-4 days <br />0.00306 hours <br />1.818783e-5 weeks <br />4.1855e-6 months <br /> and 21 minute period between 1246 hours0.0144 days <br />0.346 hours <br />0.00206 weeks <br />4.74103e-4 months <br /> on December 15, 1992, and 0007 hours8.101852e-5 days <br />0.00194 hours <br />1.157407e-5 weeks <br />2.6635e-6 months <br /> on December 16, 1992. This was discovered while recording the sample collection information in the Chemistry Log Book. The night shift chemistry technician noticed that the last offgas sample had been collected at 1246 hours0.0144 days <br />0.346 hours <br />0.00206 weeks <br />4.74103e-4 months <br /> on December 15, 1992, and not 1615 hours0.0187 days <br />0.449 hours <br />0.00267 weeks <br />6.145075e-4 months <br /> as assumed by the night shift lead chemistry technician.
WNP-2 entered a Limiting Condition for Operation (LCO) at 0740 hours0.00856 days <br />0.206 hours <br />0.00122 weeks <br />2.8157e-4 months <br /> on December 12, 1992, for explosive gas (hydrogen) monitoring instrumentation, when Offgas Analyzer 12A (OG-AY-12A) was taken out of service for maintenance. Main condenser offgas samples were being collected every four hours in accordance with Technical Specification 3.3.7.12 and Table 3.3.7.12-1. The last four hour sample was collected at 1246 hours0.0144 days <br />0.346 hours <br />0.00206 weeks <br />4.74103e-4 months <br /> on December 15, 1992, The hydrogen concentration was found to be less than one percent by volume, which is acceptable (below the four percent Technical Specifications limit).
Prior to the next scheduled four hour sample collection time at 1615 hours0.0187 days <br />0.449 hours <br />0.00267 weeks <br />6.145075e-4 months <br />, the Operations Shift Manager notified the day shift lead chemistry technician that the sample collection interval could be increased to eight hours. This is in accordance with the Technical Specifications, if the offgas recombiner temperature remains constant and reactor thermal power has not changed. A decision was made by the chemistry supervisor to start the eight hour clock from the last scheduled sample collection time at 1215 hours0.0141 days <br />0.338 hours <br />0.00201 weeks <br />4.623075e-4 months <br />, making the next sample due at 2015 hours0.0233 days <br />0.56 hours <br />0.00333 weeks <br />7.667075e-4 months <br />. Shift turnover to night shift occurred at approximately 1830 hours0.0212 days <br />0.508 hours <br />0.00303 weeks <br />6.96315e-4 months <br />.
UCENSEE EVENT REPORT (Ol)
TEXT CONTlNUATION FACILITY NAHE (I) DOCKET NUHSER (2) LER NUHSER (8) PAGE (3)
Year Number ev. No.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 2 046 00 3 F 6 TITLE (4)
FAILURE TO COLLECT AN OFFGAS SAMPLE WITHIN TECHNICAL SPECIFICATION TIME REQUIREMENTS The night shift lead chemistry technician was made aware of the new eight hour sample collection schedule at turnover. However, he did not know when the last sample was collected. The last sample time was verbally stated by the day shift lead technician at turnover, but was not heard or was misunderstood. The night shift lead technician assumed the last sample time to be 1615 hours0.0187 days <br />0.449 hours <br />0.00267 weeks <br />6.145075e-4 months <br /> based upon the previous night' sample collection schedule and the time of shift turnover. As a result, he mistakenly thought the next sample was due at 0015 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br /> on December 16, 1992. Accordingly, he assigned his on-shift chemistry technician to collect the offgas sample at 0007 on December 16, 1992, three hours and 21 minutes beyond the eight hour Technical Specifications frequency requirement. The offgas sample was analyzed and the hydrogen concentration was found to be less than one percent. The chemistry department supervision and the Shift Manager were not immediately notified of the Technical Specifications violation when it was discovered by the night shift chemistry technician. Notification was not made until day shift on December 16, 1992.
Immedi te rrectiv Ac ion No immediate corrective actions were required since the Technical Specification surveillance was current at the time of the event discovery.
F herEvlI i n n orreciv A i n Further Evalua i n This event is reportable under 10CFR50.73(a)(2)(i)(B) as "Any operation or condition prohibited by the plant's Technical Specifications."
Investigation of this event found that the lead chemistry technicians rely on informal aids and verbal communication almost entirely to pass on information between shifts. The Chemistry LCO Log Book is the official document for controlling LCO sampling times in accordance with PPM 12.13.33, but is not consistently reviewed by the lead chemistry technicians during shift turnovers. The Chemistry Shift Turnover sheet, the Chemistry Log Book, and a 'white the chemistry offices are the principal references. Although all are informal aids, they are board'utside standard parts of chemistry shift turnover work practice. When used together, they provide all necessary turnover information, including LCO sample times. However, the Chemistry Shift Turnover sheet was found not to be adequate to assure required LCO sample times are identified, if used alone. A review of past Chemistry Shift Turnover sheets revealed a wide variance in the information recorded, and prior to this event, recording sample times on the turnover sheet was uncommon.
LICENSEE EVENT REPORT (OI)
TEXT CONTINUATION FACILITY NAME (I) OOCKET NUMBER (2) LER NUMBER (6) AGE (3) ear umber ev. No.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 2 046 00 4 F 6 TITLE (4)
FAILURE TO COLLECT AN OFFGAS SAMPLE WITKIN TECHNICAL SPECIFICATION TIME REQUIREMENTS On December 15, 1992, shift turnover to night shift occurred in the hallway outside of the chemistry laboratory. The oncoming night shift lead chemistry technician was temporarily unable to clear the portal radiation monitor to access the chemistry office, the normal turnover location. The only reference document used during the shift turnover was the Chemistry Shift Turnover sheet, which did not list the required LCO sample time. When the night shift lead technician later accessed the chemistry office, he did not review the Chemistry LCO Log Book, the "white board", or the Chemistry Log Book to confirm the time the next offgas sample was due. These sources all had the correct required information.
The root cause of this event was a work practices personnel error. The night shift lead chemistry technician did not verify the next required sample time during shift turnover or by reviewing appropriate up-to-date documents. This inattention to detail led to an incorrect assumption that resulted in an offgas sample not being collected within the required time limitations.
A contributing cause was that the chemistry department lacks formal requirements for implementing policies and practices on conduct and duties of chemistry personnel. Management expectations for lead chemistry technician duties and minimum log entries were disseminated through a memorandum dated July 19, 1991. The lead technicians were found not to be in full compliance with the memorandum required action of "review log books".
Further C rrective Action On December 16, 1992, an Interoffice Memorandum from the Chemistry Department Manager, concerning this event, was distributed to all chemistry department personnel. The memorandum stressed the importance of strict compliance to the Technical Specifications, and outlined management's expectations as they pertain to shift turnover and the use of the Chemistry Log Book. Each chemistry department employee was required to read and sign for having read the memorandum.
- 2. Procedure PPM 1.3.58, Conduct of Chemistry, will be issued by January 31, 1993. This procedure incorporates the information from previous appropriate memorandums and will help assure consistent implementation of management expectations. Moreover, the procedure will be required reading for chemistry department personnel when issued and following changes or updates, serving to reemphasize department policies and practices. Procedure PPM 1.3.58 will address requirements for shift chemistry personnel attendance and access to logs, personnel aids and pertinent information during turnovers. The Chemistry Shift Turnover sheet will become part of the procedure, requiring a sign off for reading and understanding required turnover items and references, including the LCO Log Book. The procedure will also include requirements to immediately notify department supervision and
LICENSEE EVENT REPORT (0)
TEXT CONTINUAT(ON ACILITY NAHE (1) DOCKET NUHBER (2) LER NUHBER (8) AGE (3) ear umber ev. No.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 2 046 00 5 F 6 ITLE (4)
FAILURE TO COLLECT AN OFFGAS SAMPLE WITHIN TECHNICAL SPECIFICATION TINE REQUIREMENTS the Shift Manager of conditions that could potentially result in a violation of a Technical Specification LCO. A Chemistry Standing Order was issued on December 16, 1992 to this effect as a corrective action for LER 92-038 and this event. The Standing Order had not been implemented prior to this December 15, 1992 event because management's original intent was to take credit for the procedure that was to be issued in mid-January, 1993.
fe i nifi n There is no safety significance associated with this event. The offgas was sampled and analyzed within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> of the previous sample. The hydrogen concentration of both the pre-event and post-event samples was less than one percent by volume, which is within the Technical Specification limit of four percent hydrogen by volume, The redundant Main Condenser Offgas Explosive Gas Monitor (OG-AY-12B) was in service during the period of OG-AY-12A inoperability. OG-AY-12B indicated the offgas hydrogen concentration to be less than one percent during this period, validating the grab sample data.
imilar Event LER 92-038, "Failure to Perform Offgas Analysis Within Technical Specification Time Requirements." This event occurred on October 14, 1992, with the related root cause being a work practice personnel error resulting in a failure to meet a Technical Specification time limitation. Also related, was the problem of slow notification of supervision and the Shift Manager of the Technical Specification violation. The corrective actions were to counsel the chemistry technicians, clarify guidance in the Chemistry LCO Log Book, and initiate a department practice to immediately notify supervision and the Shift Manager of potential Technical Specification LCO violations. The corrective action for slow notification of supervision and the Shift Manager had not been completed at the time of the current event (due January 4, 1993). All other corrective actions had been completed. The previous corrective actions were ineffective in preventing a similar event because the chemistry department lacked formal requirements for implementing department policies and practices. Procedure PPM 1.3.58, Conduct of Chemistry, should prevent recurrence of another similar event by assuring consistent implementation of management expectations, and procedurally requiring review of specified shift turnover items and references relating to Technical Specification LCO activities.
LICENSEE EVENT REPORT TEXT CONTINUATION (4)
FACILITY HAME (I) OOCKET HUHBER (2) LER HUM8ER (8) AGE (3)
Year umber ev. Ho.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 2 46 00 6 OF 6 TITLE (4)
FAILURE TO COLLECT AN OFFGAS SAMPLE WITHIN TECHNICAL SPECIFICATION TIME REQUIREMENTS EIIS Information Text Reference EIIS Reference system ~n~)~on ~n Offgas Analyzer 12A AY (OG-AY-12A)
Offgas Analyzer 12B AY OG-AY-12B)