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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML20029E3351994-05-10010 May 1994 LER 94-006-00:on 940415,both Trains of CREVS Declared Inoperable.Caused by Tornado Warning & Sighting of Tornado Moving Toward Plant.Tornado Warnings downgraded.W/940510 Ltr ML20029E2021994-05-0909 May 1994 LER 94-004-00:on 940408,determined That TS Pressurizer Cooldown Limit Exceeded on 930618 & Not Restored within Required Timeframe.Caused by Unanticipated Sys Interaction. SI for Check Valve Opening Tests revised.W/940509 Ltr ML20029D8151994-05-0303 May 1994 LER 94-005-00:on 940403,inadvertent Fwis Occurred.Caused by Personnel Failure to Follow Work Document Instructions. Corrective Action:Individuals Were Counseled on Requirements to Follow Work Document Instruction steps.W/940503 Ltr ML20046B8351993-07-30030 July 1993 LER 93-017-00:on 930621,discovered 24-hour Telephone Notification Had Not Been Carried Out as Required by TS LCO 3.7.11.1 Action Statement (b)(2)(a) Due to Personnel Error. NRC Informed of Missed notification.W/930730 Ltr ML20046B8501993-07-30030 July 1993 LER 93-018-00:on 930704,DG Started Due to Improper WO Planning.Restored Power to 1BB Shutdown Board & Stopped Running DGs.W/930730 Ltr ML20046A4691993-07-19019 July 1993 LER 93-016-00:on 930619,Phase A,Auxiliary Bldg & Containment Isolations Manually Initiated as Result of Fuel Assembly Failing to Remain in Upright Position After Being Released. All Fuel Movement stopped.W/930719 Ltr ML20045J0111993-07-14014 July 1993 LER 93-015-00:on 930614,1A Start Bus Alternate Feeder Breaker Tripped Upon Start of Unit 1 RCP Which Resulted in Start of DG Due to Current Transformer Wired Incorrectly. Restored Offsite Power & Secured Final DG.W/930714 Ltr ML20045H0171993-07-12012 July 1993 LER 93-014-00:on 930611,determined That Inadequate Ventilation Design Resulted in Potential Inoperability of Vital Power Equipment.Design Being modified.W/930712 Ltr ML20045B9951993-06-15015 June 1993 LER 93-004-01:on 930222,determined That Blind Flange on Elevation 734 Personnel Airlock Outer Housing Leaking.Due to Improper Installation of Blind Flange.Evaluation Performed of Other 14 Double O-ring Blind flanges.W/930615 Ltr ML20045B9311993-06-10010 June 1993 LER 93-013-00:on 930514,fire Watch Was Not Performed within Time Frame Required by Tech Specs Due to Inadequate Supervision by Fire Protection Foreman.Fire Watch Patrol reestablished.W/930610 Ltr ML20045A7261993-06-0707 June 1993 LER 93-011-00:on 930507,discovered That Fire Barrier Breached W/O Proper Compensatory Measures Established.On 930505,door Leading to Room Housing Containment Spray HX 1A Breached.Roving Fire Watch Established & LCO 3.7.12 Entered ML20044H4501993-06-0303 June 1993 LER 93-012-00:on 930504,apparent Failure to Properly Identify & Plug SG Tube Determined to Exceed TS Plugging Limit.Caused by eddy-current Coordinator Not Ensuring Task requirements.Eddy-current Procedure revised.W/930603 Ltr ML20044H1561993-05-28028 May 1993 LER 93-010-00:on 930430,Westinghouse Identified Error in Development of Calculations for Cold Overpressure Mitigation Sys Setpoints.Caused by Vendor Failure to Consider Elevation Difference.Engineering Evaluation Performed ML20044E6341993-05-17017 May 1993 LER 93-009-00:on 930417,TS Surveillance Not Performed for Three Pipe Support Snubbers Because of Omission of Snubbers from Surveillance Instruction for Visual Insp.Snubbers Visually Inspected & Functionally tested.W/930517 Ltr ML20044B6751993-02-23023 February 1993 LER 93-001-00:on 930124,Unit 1 Ice Bed Temperature Recorder in MCR Declared Inoperable.Caused by Ineffective Communication.Appropriate Personnel Involved W/Event Have Been counseled.W/930223 Ltr ML20044B6141993-01-21021 January 1993 LER 92-026-00:on 921222,determined That Several ASME Section XI Pressure Tests Not Performed Due to Section XI Program Implementation Not Being well-defined,controlled or Documented.Test Expeditiously performed.W/930121 Ltr ML20024H2441991-05-22022 May 1991 LER 91-007-00:on 910422,LCO 3.0.3 Entered When Shaft of Train a Main Control Room Air Handling Unit Failed from Fatigue & Train B Out of Svc for Maint.Caused by Shaft Misalignment.New Shaft installed.W/910522 Ltr ML20029C1761991-03-21021 March 1991 LER 91-002-00:on 910211,unit Operated in Condition Prohibited by Tech Spec 3.3.3.8 Limiting Condition for Operation.Cause Under Investigation.Night Order Issued to Personnel Re Removal of Equipment from svc.W/910321 Ltr ML20029C1231991-03-18018 March 1991 LER 90-016-01:on 901117,determined That Calibr of Nuclear Instrumentation Sys intermediate-range Channels Set Nonconservatively.Caused by Lack of Operability Control for Rod Motion.Action Plan developed.W/910318 Ltr ML20029A6711991-02-25025 February 1991 LER 91-002-00:on 910124,LCOs 3.0.5 & 3.8.1.1 Entered When Both Trains of Emergency Gas Treatment Sys Declared Inoperable.Caused by Blown Fuse & Excessive Cycling of Air Start Sys.Fuse replaced.W/910225 Ltr ML20028H0331990-09-27027 September 1990 LER 90-019-00:on 900828,failure to Update P-250 Plant Computer Constants Resulted in Axial Flux Difference.Caused by Inadequate Procedures & Inappropriate Personnel Actions. Procedure 0-PI-NXX-092-001.0 revised.W/900927 Ltr ML20028G9201990-09-26026 September 1990 LER 90-020-00:on 900829,ventilation Sys Inoperable Due to Train B Diesel Generator Out of Svc.Caused by Stuck Microswitch Contacts on Pressure Switch 0-PS-311-172. Pressure Switch Adjusted & Returned to svc.W/900926 Ltr ML20044A9361990-07-0909 July 1990 LER 90-011-00:on 900608,determined That Actual Nuclear Instrumentation Sys Power Range Detector Currents Were 20% to 31% Lower than Predicted.Caused by Calibr Values Being Incorrectly Calculated.Channels corrected.W/900709 Ltr ML20044A3241990-06-25025 June 1990 LER 90-010-00:on 900526,limiting Condition for Operation Entered Because MSIV Failed to Close When Another MSIV Inoperable for Maint.Cause Attributed to Valve Stem & Valve Guide Binding.Operations Training Ltr issued.W/900625 Ltr ML20043H5091990-06-21021 June 1990 LER 90-009-00:on 900527,automatic Start of Auxiliary Feedwater Pumps Occurred When Both Main Feedwater Pumps Placed in Tripped Condition.Caused by Personnel Error.Trip Circuitry Reset & Operators counseled.W/900621 Ltr ML20043E5401990-06-0707 June 1990 LER 90-008-00:on 900514,two Control Room Isolations Occurred as Result of Spurious Spikes.Caused by Loose Terminations on Relay Socket.Loose Connections Properly terminated.W/900607 Ltr ML20043A4211990-05-16016 May 1990 LER 90-010-00:on 900416,containment Ventilation Isolation Occurred.Caused by Allowing Gaseous Radiation Level to Increase Too Close to Alarm Setpoint.Recovery from Isolation initiated.W/900516 Ltr ML20043A2261990-05-14014 May 1990 LER 90-009-00:on 900404,lower Containment Radiation Monitor Found Inoperable & Lower Containment Atmosphere Aligned to Upper Containment Radiation Monitor During Sampling.Caused by Personnel Error.Chemistry Training revised.W/900514 Ltr ML20043A2271990-05-14014 May 1990 LER 90-006-00:on 900414,auxiliary Bldg Isolation Occurred from Spent Fuel Pit Area Radiation Monitors 0-RM-90-102 & 103.Caused by Personnel Error.Training Ltr Issued to Instrument Mechanics & Operations personnel.W/900514 Ltr ML20043A2201990-05-14014 May 1990 LER 90-007-00:on 900413,discovered That Tech Spec Surveillance Requirement Not Performed within Required Interval.Caused by Personnel Error.Surveillance Successfully Performed Since missed.W/900514 Ltr ML20042G7861990-05-0909 May 1990 LER 90-005-00:on 900409,emergency Start of Four Emergency Diesel Generators Occurred While Attempting Transfer of Power.Caused by Personnel Error.Individuals Reprimanded, Training Initiated & Procedures revised.W/900509 Ltr ML20042G7931990-05-0909 May 1990 LER 90-008-00:on 900410,reactor Trip Occurred Resulting from General Warning Alarm on Both Trains of Solid State Protection Sys.Caused by Personnel Error.Individuals Disciplined & Site Wide Message distributed.W/900509 Ltr ML20042F3741990-05-0202 May 1990 LER 90-003-00:on 900404,control Room Ventilation Sys (CRVS) Transferred to Pressurization Mode.Caused by Electrical Transient in Vital Instrument Ac Bus PY-21A.CRVS Reset & Returned to Normal Operating modes.W/900502 Ltr ML20042E4191990-04-13013 April 1990 LER 90-007-00:on 900317 & 26,containment Ventilation Isolations Occurred During Purge Activities.Caused by Inadequate Procedural Guidance for Setpoint Determination. Alarm & Trip Setpoints increased.W/900413 Ltr ML20042E2021990-04-13013 April 1990 LER 90-005-00:on 900315,inadvertent Containment Vent Isolation Occurred While Preparing to Purge Containment. Caused by Lack of Attention to Detail by Operator.Operator Counseled & Received Administrative reprimand.W/900413 Ltr ML20012F5221990-04-0505 April 1990 LER 90-006-00:on 900307,containment Ventilation Isolation Occurred.Caused by Containment Particulate Level Too Close to Setpoint.Module Replaced.Radiation Alarm Setpoint Increased from 10% to 40% of Tech Spec limit.W/900406 Ltr ML20012D8611990-03-23023 March 1990 LER 90-004-00:on 900221,handswitches Controlling Operation of Isolation Valves on Steam Supply Line to Auxiliary Feedwater Pump Found in Manual Position.Cause Undetermined. Handswitches Placed in P-auto position.W/900323 Ltr ML20012C4271990-03-12012 March 1990 LER 90-003-00:on 900211,inadvertent Containment Vent Isolation Occurred.Caused by Lack of Attention to Detail in That Operator Did Not Look Closely Enough at Switch Designations.Personnel Involved counseled.W/900312 Ltr ML20011F7191990-03-0101 March 1990 LER 89-031-01:on 891205,RHR Pumps Determined to Have Deadheading Problem Identified by NRC Bulletin 88-004.Caused by Inadequate Technical Response to Bulletin.Training Ltr Issued to 10CFR50.59 reviewers.W/900301 Ltr ML20011F7421990-02-26026 February 1990 LER 90-002-00:on 900127,control Room Isolation Occurred When Circuit Breaker Opened Supplying Power to Radiation Monitor. Caused by Failure by Personnel to Exercise Sufficient Caution.Responsible Engineers reinstructed.W/900226 Ltr ML20011F7391990-02-26026 February 1990 LER 90-002-00:on 891122,value for Distance from Floor to Ctr Line of Level Switch 2-LS-87-21 Transposed in Variable Leg Calculation.Caused by Inattention to Detail.Procedure Revised to Replace Incorrect setpoint.W/900226 Ltr ML20006E3311990-02-0909 February 1990 LER 90-001-00:on 900112,Limiting Condition for Operation 3.0.3 Entered When Three of Four Lower Compartment Cooler Fan Motors Exceeded Lubrication Frequency.Caused by Personnel Error.Personnel counseled.W/900209 Ltr ML20006D5341990-02-0707 February 1990 LER 90-001-00:on 900108,discovered That Several ERCW Valves Not Being Periodically Verified to Be Correct.Caused by Personnel Error During Procedure Revs & Workplan Reviews. Info Notice Issued to Workplan reviewers.W/900207 Ltr ML19354E1631990-01-22022 January 1990 LER 89-036-00:on 891221,discovered That Surveillance Test Results Used for Declaring Diesel Generator 1B-B Operable Deficient.Caused by Instruction Not Including 60 Minute Run Time.Event Will Be Reviewed w/supervisors.W/900122 Ltr ML19354D8941990-01-16016 January 1990 LER 89-034-00:on 891215,leak Identified from Fitting on Vol Control Tank Level Transmitter & Auxiliary Bldg Evacuated, Preventing Fire Watch Patrol from Entering Bldg for Hourly Rounds.Fitting tightened.W/900116 Ltr ML19354D9061990-01-16016 January 1990 LER 89-033-00:on 891216,refueling Water Storage Tank Level Transmitters Failed High Due to Freezing from Extremely Cold Weather & Inappropriate Use of Calculations.Engineering Procedures Revised & Heating Installed in encl.W/900116 Ltr ML20005F8851990-01-0909 January 1990 LER 89-035-00:on 891210,turbine/reactor Trip Occurred from hi-hi Feedwater Level of 75% in Steam Generator 3.Caused by Failure of Loop 3 Main Feedwater Regulating Valve to Close. Equipment Adjusted & repaired.W/900109 Ltr ML20005E0801989-12-22022 December 1989 LER 89-032-00:on 891205,RHR Pumps Determined to Have Deadheading Problem,Per NRC Bulletin 88-004,resulting in Plant Operation Outside Design Basis.On 891128,RHR Pump Exceeded Head Criteria.Pumps started.W/891222 Ltr ML20005E0831989-12-22022 December 1989 LER 89-032-00:on 891201,discovered That Tech Spec Surveillance Requirement to Verify That Valves 1-67-748 & 2-67-748 in Open Position Not Met.Caused by Personnel Error.Correct Valve Position verified.W/891222 Ltr ML20005E1161989-12-22022 December 1989 LER 89-030-00:on 891204,fire Suppression Sys Deluge Valve Isolated More than 1 H W/O Required Continuous Fire Watch Establishment.Caused by Personal Communication Breakdown. Valve Opened & Foreman in Charge counseled.W/891222 Ltr 1994-05-09
[Table view] Category:RO)
MONTHYEARML20029E3351994-05-10010 May 1994 LER 94-006-00:on 940415,both Trains of CREVS Declared Inoperable.Caused by Tornado Warning & Sighting of Tornado Moving Toward Plant.Tornado Warnings downgraded.W/940510 Ltr ML20029E2021994-05-0909 May 1994 LER 94-004-00:on 940408,determined That TS Pressurizer Cooldown Limit Exceeded on 930618 & Not Restored within Required Timeframe.Caused by Unanticipated Sys Interaction. SI for Check Valve Opening Tests revised.W/940509 Ltr ML20029D8151994-05-0303 May 1994 LER 94-005-00:on 940403,inadvertent Fwis Occurred.Caused by Personnel Failure to Follow Work Document Instructions. Corrective Action:Individuals Were Counseled on Requirements to Follow Work Document Instruction steps.W/940503 Ltr ML20046B8351993-07-30030 July 1993 LER 93-017-00:on 930621,discovered 24-hour Telephone Notification Had Not Been Carried Out as Required by TS LCO 3.7.11.1 Action Statement (b)(2)(a) Due to Personnel Error. NRC Informed of Missed notification.W/930730 Ltr ML20046B8501993-07-30030 July 1993 LER 93-018-00:on 930704,DG Started Due to Improper WO Planning.Restored Power to 1BB Shutdown Board & Stopped Running DGs.W/930730 Ltr ML20046A4691993-07-19019 July 1993 LER 93-016-00:on 930619,Phase A,Auxiliary Bldg & Containment Isolations Manually Initiated as Result of Fuel Assembly Failing to Remain in Upright Position After Being Released. All Fuel Movement stopped.W/930719 Ltr ML20045J0111993-07-14014 July 1993 LER 93-015-00:on 930614,1A Start Bus Alternate Feeder Breaker Tripped Upon Start of Unit 1 RCP Which Resulted in Start of DG Due to Current Transformer Wired Incorrectly. Restored Offsite Power & Secured Final DG.W/930714 Ltr ML20045H0171993-07-12012 July 1993 LER 93-014-00:on 930611,determined That Inadequate Ventilation Design Resulted in Potential Inoperability of Vital Power Equipment.Design Being modified.W/930712 Ltr ML20045B9951993-06-15015 June 1993 LER 93-004-01:on 930222,determined That Blind Flange on Elevation 734 Personnel Airlock Outer Housing Leaking.Due to Improper Installation of Blind Flange.Evaluation Performed of Other 14 Double O-ring Blind flanges.W/930615 Ltr ML20045B9311993-06-10010 June 1993 LER 93-013-00:on 930514,fire Watch Was Not Performed within Time Frame Required by Tech Specs Due to Inadequate Supervision by Fire Protection Foreman.Fire Watch Patrol reestablished.W/930610 Ltr ML20045A7261993-06-0707 June 1993 LER 93-011-00:on 930507,discovered That Fire Barrier Breached W/O Proper Compensatory Measures Established.On 930505,door Leading to Room Housing Containment Spray HX 1A Breached.Roving Fire Watch Established & LCO 3.7.12 Entered ML20044H4501993-06-0303 June 1993 LER 93-012-00:on 930504,apparent Failure to Properly Identify & Plug SG Tube Determined to Exceed TS Plugging Limit.Caused by eddy-current Coordinator Not Ensuring Task requirements.Eddy-current Procedure revised.W/930603 Ltr ML20044H1561993-05-28028 May 1993 LER 93-010-00:on 930430,Westinghouse Identified Error in Development of Calculations for Cold Overpressure Mitigation Sys Setpoints.Caused by Vendor Failure to Consider Elevation Difference.Engineering Evaluation Performed ML20044E6341993-05-17017 May 1993 LER 93-009-00:on 930417,TS Surveillance Not Performed for Three Pipe Support Snubbers Because of Omission of Snubbers from Surveillance Instruction for Visual Insp.Snubbers Visually Inspected & Functionally tested.W/930517 Ltr ML20044B6751993-02-23023 February 1993 LER 93-001-00:on 930124,Unit 1 Ice Bed Temperature Recorder in MCR Declared Inoperable.Caused by Ineffective Communication.Appropriate Personnel Involved W/Event Have Been counseled.W/930223 Ltr ML20044B6141993-01-21021 January 1993 LER 92-026-00:on 921222,determined That Several ASME Section XI Pressure Tests Not Performed Due to Section XI Program Implementation Not Being well-defined,controlled or Documented.Test Expeditiously performed.W/930121 Ltr ML20024H2441991-05-22022 May 1991 LER 91-007-00:on 910422,LCO 3.0.3 Entered When Shaft of Train a Main Control Room Air Handling Unit Failed from Fatigue & Train B Out of Svc for Maint.Caused by Shaft Misalignment.New Shaft installed.W/910522 Ltr ML20029C1761991-03-21021 March 1991 LER 91-002-00:on 910211,unit Operated in Condition Prohibited by Tech Spec 3.3.3.8 Limiting Condition for Operation.Cause Under Investigation.Night Order Issued to Personnel Re Removal of Equipment from svc.W/910321 Ltr ML20029C1231991-03-18018 March 1991 LER 90-016-01:on 901117,determined That Calibr of Nuclear Instrumentation Sys intermediate-range Channels Set Nonconservatively.Caused by Lack of Operability Control for Rod Motion.Action Plan developed.W/910318 Ltr ML20029A6711991-02-25025 February 1991 LER 91-002-00:on 910124,LCOs 3.0.5 & 3.8.1.1 Entered When Both Trains of Emergency Gas Treatment Sys Declared Inoperable.Caused by Blown Fuse & Excessive Cycling of Air Start Sys.Fuse replaced.W/910225 Ltr ML20028H0331990-09-27027 September 1990 LER 90-019-00:on 900828,failure to Update P-250 Plant Computer Constants Resulted in Axial Flux Difference.Caused by Inadequate Procedures & Inappropriate Personnel Actions. Procedure 0-PI-NXX-092-001.0 revised.W/900927 Ltr ML20028G9201990-09-26026 September 1990 LER 90-020-00:on 900829,ventilation Sys Inoperable Due to Train B Diesel Generator Out of Svc.Caused by Stuck Microswitch Contacts on Pressure Switch 0-PS-311-172. Pressure Switch Adjusted & Returned to svc.W/900926 Ltr ML20044A9361990-07-0909 July 1990 LER 90-011-00:on 900608,determined That Actual Nuclear Instrumentation Sys Power Range Detector Currents Were 20% to 31% Lower than Predicted.Caused by Calibr Values Being Incorrectly Calculated.Channels corrected.W/900709 Ltr ML20044A3241990-06-25025 June 1990 LER 90-010-00:on 900526,limiting Condition for Operation Entered Because MSIV Failed to Close When Another MSIV Inoperable for Maint.Cause Attributed to Valve Stem & Valve Guide Binding.Operations Training Ltr issued.W/900625 Ltr ML20043H5091990-06-21021 June 1990 LER 90-009-00:on 900527,automatic Start of Auxiliary Feedwater Pumps Occurred When Both Main Feedwater Pumps Placed in Tripped Condition.Caused by Personnel Error.Trip Circuitry Reset & Operators counseled.W/900621 Ltr ML20043E5401990-06-0707 June 1990 LER 90-008-00:on 900514,two Control Room Isolations Occurred as Result of Spurious Spikes.Caused by Loose Terminations on Relay Socket.Loose Connections Properly terminated.W/900607 Ltr ML20043A4211990-05-16016 May 1990 LER 90-010-00:on 900416,containment Ventilation Isolation Occurred.Caused by Allowing Gaseous Radiation Level to Increase Too Close to Alarm Setpoint.Recovery from Isolation initiated.W/900516 Ltr ML20043A2261990-05-14014 May 1990 LER 90-009-00:on 900404,lower Containment Radiation Monitor Found Inoperable & Lower Containment Atmosphere Aligned to Upper Containment Radiation Monitor During Sampling.Caused by Personnel Error.Chemistry Training revised.W/900514 Ltr ML20043A2271990-05-14014 May 1990 LER 90-006-00:on 900414,auxiliary Bldg Isolation Occurred from Spent Fuel Pit Area Radiation Monitors 0-RM-90-102 & 103.Caused by Personnel Error.Training Ltr Issued to Instrument Mechanics & Operations personnel.W/900514 Ltr ML20043A2201990-05-14014 May 1990 LER 90-007-00:on 900413,discovered That Tech Spec Surveillance Requirement Not Performed within Required Interval.Caused by Personnel Error.Surveillance Successfully Performed Since missed.W/900514 Ltr ML20042G7861990-05-0909 May 1990 LER 90-005-00:on 900409,emergency Start of Four Emergency Diesel Generators Occurred While Attempting Transfer of Power.Caused by Personnel Error.Individuals Reprimanded, Training Initiated & Procedures revised.W/900509 Ltr ML20042G7931990-05-0909 May 1990 LER 90-008-00:on 900410,reactor Trip Occurred Resulting from General Warning Alarm on Both Trains of Solid State Protection Sys.Caused by Personnel Error.Individuals Disciplined & Site Wide Message distributed.W/900509 Ltr ML20042F3741990-05-0202 May 1990 LER 90-003-00:on 900404,control Room Ventilation Sys (CRVS) Transferred to Pressurization Mode.Caused by Electrical Transient in Vital Instrument Ac Bus PY-21A.CRVS Reset & Returned to Normal Operating modes.W/900502 Ltr ML20042E4191990-04-13013 April 1990 LER 90-007-00:on 900317 & 26,containment Ventilation Isolations Occurred During Purge Activities.Caused by Inadequate Procedural Guidance for Setpoint Determination. Alarm & Trip Setpoints increased.W/900413 Ltr ML20042E2021990-04-13013 April 1990 LER 90-005-00:on 900315,inadvertent Containment Vent Isolation Occurred While Preparing to Purge Containment. Caused by Lack of Attention to Detail by Operator.Operator Counseled & Received Administrative reprimand.W/900413 Ltr ML20012F5221990-04-0505 April 1990 LER 90-006-00:on 900307,containment Ventilation Isolation Occurred.Caused by Containment Particulate Level Too Close to Setpoint.Module Replaced.Radiation Alarm Setpoint Increased from 10% to 40% of Tech Spec limit.W/900406 Ltr ML20012D8611990-03-23023 March 1990 LER 90-004-00:on 900221,handswitches Controlling Operation of Isolation Valves on Steam Supply Line to Auxiliary Feedwater Pump Found in Manual Position.Cause Undetermined. Handswitches Placed in P-auto position.W/900323 Ltr ML20012C4271990-03-12012 March 1990 LER 90-003-00:on 900211,inadvertent Containment Vent Isolation Occurred.Caused by Lack of Attention to Detail in That Operator Did Not Look Closely Enough at Switch Designations.Personnel Involved counseled.W/900312 Ltr ML20011F7191990-03-0101 March 1990 LER 89-031-01:on 891205,RHR Pumps Determined to Have Deadheading Problem Identified by NRC Bulletin 88-004.Caused by Inadequate Technical Response to Bulletin.Training Ltr Issued to 10CFR50.59 reviewers.W/900301 Ltr ML20011F7421990-02-26026 February 1990 LER 90-002-00:on 900127,control Room Isolation Occurred When Circuit Breaker Opened Supplying Power to Radiation Monitor. Caused by Failure by Personnel to Exercise Sufficient Caution.Responsible Engineers reinstructed.W/900226 Ltr ML20011F7391990-02-26026 February 1990 LER 90-002-00:on 891122,value for Distance from Floor to Ctr Line of Level Switch 2-LS-87-21 Transposed in Variable Leg Calculation.Caused by Inattention to Detail.Procedure Revised to Replace Incorrect setpoint.W/900226 Ltr ML20006E3311990-02-0909 February 1990 LER 90-001-00:on 900112,Limiting Condition for Operation 3.0.3 Entered When Three of Four Lower Compartment Cooler Fan Motors Exceeded Lubrication Frequency.Caused by Personnel Error.Personnel counseled.W/900209 Ltr ML20006D5341990-02-0707 February 1990 LER 90-001-00:on 900108,discovered That Several ERCW Valves Not Being Periodically Verified to Be Correct.Caused by Personnel Error During Procedure Revs & Workplan Reviews. Info Notice Issued to Workplan reviewers.W/900207 Ltr ML19354E1631990-01-22022 January 1990 LER 89-036-00:on 891221,discovered That Surveillance Test Results Used for Declaring Diesel Generator 1B-B Operable Deficient.Caused by Instruction Not Including 60 Minute Run Time.Event Will Be Reviewed w/supervisors.W/900122 Ltr ML19354D8941990-01-16016 January 1990 LER 89-034-00:on 891215,leak Identified from Fitting on Vol Control Tank Level Transmitter & Auxiliary Bldg Evacuated, Preventing Fire Watch Patrol from Entering Bldg for Hourly Rounds.Fitting tightened.W/900116 Ltr ML19354D9061990-01-16016 January 1990 LER 89-033-00:on 891216,refueling Water Storage Tank Level Transmitters Failed High Due to Freezing from Extremely Cold Weather & Inappropriate Use of Calculations.Engineering Procedures Revised & Heating Installed in encl.W/900116 Ltr ML20005F8851990-01-0909 January 1990 LER 89-035-00:on 891210,turbine/reactor Trip Occurred from hi-hi Feedwater Level of 75% in Steam Generator 3.Caused by Failure of Loop 3 Main Feedwater Regulating Valve to Close. Equipment Adjusted & repaired.W/900109 Ltr ML20005E0801989-12-22022 December 1989 LER 89-032-00:on 891205,RHR Pumps Determined to Have Deadheading Problem,Per NRC Bulletin 88-004,resulting in Plant Operation Outside Design Basis.On 891128,RHR Pump Exceeded Head Criteria.Pumps started.W/891222 Ltr ML20005E0831989-12-22022 December 1989 LER 89-032-00:on 891201,discovered That Tech Spec Surveillance Requirement to Verify That Valves 1-67-748 & 2-67-748 in Open Position Not Met.Caused by Personnel Error.Correct Valve Position verified.W/891222 Ltr ML20005E1161989-12-22022 December 1989 LER 89-030-00:on 891204,fire Suppression Sys Deluge Valve Isolated More than 1 H W/O Required Continuous Fire Watch Establishment.Caused by Personal Communication Breakdown. Valve Opened & Foreman in Charge counseled.W/891222 Ltr 1994-05-09
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20212J6311999-10-0101 October 1999 SER Accepting Request for Relief from ASME Boiler & Pressure Vessel Code,Section Xi,Requirements for Certain Inservice Insp at Plant,Unit 1 ML20217G3721999-09-30030 September 1999 Monthly Operating Repts for Sept 1999 for Sequoyah Nuclear Plant.With ML20212F0831999-09-23023 September 1999 Safety Evaluation Granting Relief from Certain Weld Insp at Sequoyah Nuclear Plant,Units 1 & 2 Pursuant to 10CFR50.55a(a)(3)(ii) for Second 10-year ISI Interval ML20212F4761999-09-23023 September 1999 Safety Evaluation Supporting Amends 246 & 237 to Licenses DPR-77 & DPR-79,respectively ML20212C4761999-08-31031 August 1999 Monthly Operating Repts for Aug 1999 for Sequoyah Nuclear Plant.With ML20210L4361999-08-0202 August 1999 Cycle 9 12-Month SG Insp Rept ML20216E3781999-07-31031 July 1999 Monthly Operating Repts for July 1999 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20210L4451999-07-31031 July 1999 Unit-2 Cycle 10 Voltage-Based Repair Criteria 90-Day Rept ML20210G6631999-07-28028 July 1999 Cycle 9 90-Day ISI Summary Rept ML20196H8621999-06-30030 June 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept ML20209H3831999-06-30030 June 1999 Monthly Operating Repts for June 1999 for Sequoyah Nuclear Plant.With ML20211F9031999-06-30030 June 1999 Cycle 9 Refueling Outage ML20196J8521999-06-28028 June 1999 Safety Evaluation Authorizing Proposed Alternative to Use Iqis for Radiography Examinations as Provided for in ASME Section III,1992 Edition with 1993 Addenda,Pursuant to 10CFR50.55a(a)(3)(i) ML20195K2951999-05-31031 May 1999 Monthly Operating Repts for May 1999 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20206Q8951999-05-0505 May 1999 Rev 0 to L36 990415 802, COLR for Sequoyah Unit 2 Cycle 10 ML20206R5031999-04-30030 April 1999 Monthly Operating Repts for April 1999 for Sequoyah Units 1 & 2.With ML20205P9811999-03-31031 March 1999 Monthly Operating Repts for Mar 1999 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20204C3111999-02-28028 February 1999 Monthly Operating Repts for Feb 1999 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20205B6631999-02-28028 February 1999 Underground Storage Tank (Ust) Permanent Closure Rept, Sequoyah Nuclear Plant Security Backup DG Ust Sys ML20203H7381999-02-18018 February 1999 Safety Evaluation of Topical Rept BAW-2328, Blended U Lead Test Assembly Design Rept. Rept Acceptable Subj to Listed Conditions ML20211A2021999-01-31031 January 1999 Non-proprietary TR WCAP-15129, Depth-Based SG Tube Repair Criteria for Axial PWSCC Dented TSP Intersections ML20198S7301998-12-31031 December 1998 Cycle 10 Voltage-Based Repair Criteria 90-Day Rept ML20199G3641998-12-31031 December 1998 Monthly Operating Repts for Dec 1998 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20197J5621998-12-0303 December 1998 Unit 1 Cycle 9 90-Day ISI Summary Rept ML20197K1161998-11-30030 November 1998 Monthly Operating Repts for Nov 1998 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20195F8061998-10-31031 October 1998 Monthly Operating Repts for Oct 1998 for Sequoyah Nuclear Plant.With ML20154H6091998-09-30030 September 1998 Monthly Operating Repts for Sept 1998 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20154H6251998-09-17017 September 1998 Rev 0 to Sequoyah Nuclear Plant Unit 1 Cycle 10 Colr ML20153B0881998-08-31031 August 1998 Monthly Operating Repts for Aug 1998 for Sequoyah Nuclear Plant.With ML20239A0631998-08-27027 August 1998 SER Accepting Licensee Response to GL 95-07, Pressure Locking & Thermal Binding of Safety-Related Power-Operated Gate Valves, for Sequoyah Nuclear Plant,Units 1 & 2 ML20236Y2091998-08-0707 August 1998 Safety Evaluation Accepting Relief Requests RP-03,RP-05, RP-07,RV-05 & RV-06 & Denying RV-07 & RV-08 ML20237B5221998-07-31031 July 1998 Monthly Operating Repts for July 1998 for Snp ML20237A4411998-07-31031 July 1998 Blended Uranium Lead Test Assembly Design Rept ML20236P6441998-07-10010 July 1998 LER 98-S01-00:on 980610,failure of Safeguard Sys Occurred for Which Compensatory Measures Were Not Satisfied within Required Time Period.Caused by Inadequate Security Procedure.Licensee Revised Procedure MI-134 ML20236R0051998-06-30030 June 1998 Monthly Operating Repts for June 1998 for Sequoyah Nuclear Plant ML20249A8981998-05-31031 May 1998 Monthly Operating Repts for May 1998 for Sequoyah Nuclear Plant,Units 1 & 2 ML20247L5141998-04-30030 April 1998 Monthly Operating Repts for Apr 1998 for Sequoyah Nuclear Plant ML20217K4471998-04-27027 April 1998 Safety Evaluation Supporting Requests for Relief 1-ISI-2 (Part 1),2-ISI-2 (Part 2),1-ISI-5,2-ISI-5,1-ISI-6,1-ISI-7, 2-ISI-7,ISPT-02,ISPT-04,ISPT-06,ISPT-07,ISPT-8,ISPT-01 & ISPT-05 ML20217E2221998-03-31031 March 1998 Monthly Operating Repts for Mar 1998 for Sequoyah Nuclear Plant ML20248L2611998-02-28028 February 1998 Monthly Operating Repts for Sequoyah Nuclear Plant,Units 1 & 2 ML20199J2571998-01-31031 January 1998 Cycle 9 Voltage-Based Repair Criteria 90-Day Rept ML20202J7911998-01-31031 January 1998 Monthly Operating Repts for Jan 1997 for Sequoyah Nuclear Plant,Units 1 & 2 ML20199J2441998-01-29029 January 1998 Snp Unit 2 Cycle Refueling Outage Oct 1997 ML20199F8531998-01-13013 January 1998 ASME Section XI Inservice Insp Summary Rept for Snp Unit 2 Refueling Outage Cycle 8 ML20199A2931997-12-31031 December 1997 Revised Monthly Operating Rept for Dec 1997 for Sequoyah Nuclear Plant,Units 1 & 2 ML20198M1481997-12-31031 December 1997 Monthly Operating Repts for Dec 1997 for Sequoyah Nuclear Plant,Units 1 & 2 ML20197J1011997-11-30030 November 1997 Monthly Operating Repts for Nov 1997 for Sequoyah Nuclear Plant,Units 1 & 2 ML20199C2951997-11-13013 November 1997 LER 97-S01-00:on 971017,vandalism of Electrical Cables Was Observed.Caused by Vandalism.Repaired Damaged Cables, Interviewed Personnel Having Potential for Being in Area at Time Damage Occurred & Walkdowns ML20199C7201997-10-31031 October 1997 Monthly Operating Repts for Oct 1997 for Sequoyah Nuclear Plant L-97-215, SG Secondary Side Loose Object Safety Evaluation1997-10-23023 October 1997 SG Secondary Side Loose Object Safety Evaluation 1999-09-30
[Table view] |
Text
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S TENNESSEE VALLEY AUTHORITY 6N 38A Lookout Place January 16, 1990 U.S. Nuclear Regulatory Commission ATTN Document Control Desk Washington, D.C. 20555 Gentlemen:
TENNESSEE VALLEY AUTHORITY - SEQUOYAH NUCLEAR PLANT UNIT 1 - DOCKET NO.
50-327 - FACILITY OPERATING LICENSE DPR LICENSEE EVENT REPORT (LER) 50-327/89033 The enclosed LER provides details concerning an entry into Limiting Condition for Operation 3.0.3 when the refueling water storage tank level channels failed and were declared inoperable because of freezing from the cold weather. This event is reported in accordance with 10 CFR 50.73, paragraph a.2.1.b.
Very truly yours.
TENNESSEE VALLEY AUTHORITY
. R. Byn esident Nuclear Power Production Enclosure cc (Enclosure):
Regional Administration U.S. Nuclear Regulatory Commission Office of Inspection and Enforcement Region II 101 Marietta Street, Suite 2900 Atlanta, Georgia 30323 INPO Records Center Institute of Nuclear Power Operations 1100 circle 75 Parkway, Suite 1500 Atlanta, Georgia 30339 NRC Resident Inspector Sequoyah Nuclear Plant 2600 Igou Ferry Road Soddy Daisy, Tennessee 37379 9001240078 900116 d PDR ADOCK 05000327 g PDC i ,
An Equal Opportunity Employer k j i
NRC 9 ORJ 304 U.S. NUCL EJJ 5.1 GUL&TWY COMMIS510N A.PPROVE D OMB NO 3160 4104
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"' Limiting Condition for Operation 3.0.3 entered when the refueling water storage tank level transmitters failed because of freezing during cold weather EVENT DATE (Si LER NUMSER (Si REPORT DAff 17) OTHE R S ACILITit$ INVOLVED (Si MONTH DAY YEAR vtAR OM L QL*y MONTH Day vEAR eacetifvhaMes DOCKET NUMBERI5 Sequoyah, Unit 2 01510 l 0 l 0 l3 l 2 l 8
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1l2 1l 6 8 9 8l 9 0l 3l 3 0l 0 0l 1 1l 6 9l 0 0 1 510 1 0 1 0 i l l OPE R ATING TM14 REPORT IS SUDMITTED PURSUANT TO THE MkOUIREMENTS OF 10 CFR l (Caece oas er more et the fenow.apl (til MODE m 1 20 40210) 20 406tel to 73teH2Hivl T3.71463 POvrt h 20 406teH1100 90 368:Hti to.73(eH2Het 73.714sl
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to 406teH1Hwl 50.73teH2thil to.73teH2HvWHBI 20 408teH1Het 50.73teH2Hel 6073mH2Hal LICENSEE CONTACT FOR TMil LER (Ill NAME TELEPHONE NUMSER aRE A CODE !
Sydney W. Spencer, Compliance Licensing Engineer 6 1115 8l4l3l-t 7 l 51 4l C COMPLEf t ONE LINE poR E ACM COMPONENT F AtLURE DESCRitED IN THIS REPORT 113)
" ' MA R ORfA E CAU$t SYSTEM COMPONENT gf "Yo$e'R$s CAUSE SYSTEM COMPONENT C-pp I I I I I I I I I 1 I i l I 4 I I I I I I I I I I l l 1 1 SUPPLEMENT AL REPORT EXPICTED (14) MONTH DAY YEAR SU0 Mission vi$ fle yes comorere EMPECTED Sv040t$310N DA TE) NO l l l A04th ACT f& amer to f 400 apaces
- e , soprose ensey fifteen senere spece typewrerfen tsaesi titi At 0357 Eastern standard time (EST) on December 16, 1989, with Unit 1 in Mode 1, the refueling water storage tank (RWST) Level Transmitters 1-LT-63-50 and 51 had failed high. At 0828 EST with Unit 2 in Mode 1, RWST Level Transmitters-2-LT-63-50, 52 had failed high. As a result, both Units entered Limiting Condition for Operation (LCO) 3.0.3 at 0357 and 0828 respectively. The failures were because of freezing from extreme cold weather. Additional transmitter failures occurred in the east main steam valve vault and outside the auxiliary building. The root cause of the freezing of the RWST sense lines was prior removal of power to heaters and thermostats installed in the transmitter enclosures due to an inappropriate use of calculations. The root cause of the freezing sense lines in the main steam valve vault was inadequate concideration of freeze protection requirements during design changes to increase ventilation flow. The root cause of transmitter sense lines freezing on the outside of the auxiliary building was insulation not in accordance with design requirements. Immediate corrective actions ,
consisted of obtaining discretionary enforcement to extend operation in LCO 3.0.3, issuing night orders to ensure adequate RWST water levels existed, providing guidance to l 4
operators for performing RWST to containment sump swapover with the level transmitters inoperable / unreliable, erecting enclosures, installing heating within enclosures, reenergizing heat tracing, and recalibrating the RWST level transmitters. Longer-term corrective action consists of (1) revision of NE's drawings and installation of qualified IE thermostats, (2) rerouting or insulation of sense lines in the valve vaults, (3) revision of engineering procedures to require documented concurrence of cross discipline review and (4) disciplining appropriate personnel.
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0 l8 TexTin A, = . ann.,wmc r annun DESCRIPTION.OF EVENT At 0357 Eastern standard time (EST) on December.16, 1989, with Unit 1 in Mode 1 (100 percent power, 578 degrees Fahrenheit (F] and 2,235 pounds per square-inch gauge
[psig]) refueling water storage tank (RWST) (EIIS Code BQ) Level Transmitters 1-LT-63-50 and 51 failed high. By 0828 EST with Unit 2 in Mode 1 (80 percent power.L571 degrees F. '
end 2,235 p-ig) RWST level Transmitters 2-LT-63-50 and 52 had also failed high. As a result of the extremely cold temperatures (Chattanooga and surrounding areas were experiencing approximately 8 degrees F-with wind chill temperatures'approximately minus ,
20 degrees F). multiple transmitter failures were occurring because of freezing of.
l- associated sense lines. As a result, Units 1 and.2 entered Limiting Condition for l Operation (LCO) 3.0.'3.at 0357 and 0828 respectively.. e In addition.to the RWST level transmitters, Flow Transmitters 2-FT-3-90A"and Pressure Transmitter 1-PT-1-9A failed high due to freezing. Transmitter.2-FT-3-90A sense line is routed on the exterior wall of the auxiliary building and provides.feedwater flow input to determine steam flow greater than feed flow coincident with' low S/0 level to initiate a reactor trip. Pressure Transmitter 1-PT-1-9A -located in the main steam valve vault, monitors low steam pressure coincident with high steam flow to initiate steam line
~
isolation and safety injection.
Listed below is a chronology of instrument failures, and LCO entries / exits,that' occurred- j' because of freezing conditions.
Unit 1
- 1. At'0357,'l-LT-63-50 and 51 failed high. LCOs 3.3.2.1,'3.3.3.7 and 3.0.3 were entered.
- 2. At 0406, 1-LT-63-52 failed high.
- 3. At 0555, 1-PT-1-9A and 1-FT-1-10A failed high. LCOs 3.3.2.1 and 3.3.3.7 were entered.
l 4. At 0649, 1-LT-63-53 failed high.
l S. On December 17, 1989, at 1845, the action statements of LCOs 3.0.3, 3.3.3.7, and 3.3.2.1 were exited.
Unit-2 -
- 1. At 0127, 2-FT-3-90A failed high. ,
-2. At 0521, 2-LT-63-52 failed high. LCO 3.3.2 was entered.
- 3. At 0828, 2-LT-63-50 failed high. LCO 3.0.3 was entered.
- 4. At 0935, 2-LT-63-51 failed high.
- 5. On December 17, 1989, at 1056, the action statements of LCOs 3.3.2, and 3.0.3 were l exited.
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- DESCRIPTION OF EVENT (Continued]
, Site Licensing personnel were notified at approximately 0400 on December 16. 1989,,of the status of'the plant concerning the RWST level-transmitters, that the condition had '
placed Unit 1 in LCO 3.0.3, and the possibility existed that both units at SQN could be placed in LC0 3.0.3. The senior NRC resident inspector was notified at 0404.regarding this, problem, and the need to request NRC discretionary enforcement to. allow time to.
~
thaw and return the transmitters operable was discussed.. Licensing personnel requested plant personnel to.obtain pertinent data on this situation in preparation for a telephone conference call with NRC. 'NRC's verbal approval of the 48-hour discretionary .
enforcement for Unit I was provided to TVA by NRC at 0615 EST on December 16', 1989. ,
Unit 2 was subsequently discussed with NRC, and the verbal 48-hour discretionary -
anforcement period to coincide with Unit 1 was granted at 1155 EST on fecember 16, 1989. The letter from TVA requesting discretionary. enforcement was submitted to NRC on December 17, 1989. NRC's formal acknowledgement of the' discretionary enforcement was received on December 18, 1989.
Interim actions established were to initiate night orders that included actions to monitor the RWST volumes by reading the narrow-range level transmitters, to remove the-manway on top of the tank once each shift to visually verify level, and to provide continuous fire watches at RWST level transmitters (this. fire watch ensured no fire dranage resulted from temporary enclosures built around the RWST level transmit'.er as the tamporary enclosures contained portable heating equipment), and to provide guidance to operators for performing RWST to containment sump swarover with the level transmitters inoperable / unreliable under. Emergency Procedure ES-1.2, " Transfer to RHR Containment Sump." Both of the referenced night orders were required'to be reviewed at each shift turnover meeting until the RWST level transmitters were returned operable.
Inunediate actions were taken by TVA to thaw the f rozen instrument sense lines and .
l prevent additional freezing from occurring. A temporary alteration control-form-(TACF) was initiated to reenergize power to the enclosure heaters and thermostats for the RWST level transmitters. A TACF 0-89-70-400 was issued-to install plastic. sheeting over the k blow-out panels in the east and west main steam valve vaults to preclude the loss of internal heating. Periodic temperature monitoring was' initiated for the main steam valve vaults. Work Request B793481 was issued to repair..the insulation, install a plastic sheeting tent and heater around Transmitter 2-FT-3-90A, and to blowdown the transmitter. When these actions began to be effective and the sense lines were thawed, the transmitters.were recalibrated and returned to service.
On December 17, l'989, the RWST level transmitter senso lines were thawed, the instruments were recalibrated, and LCO 3.0.3 was exited at 1845 and 1056 for Units 1 '
and.2 respectively.
The events leading to this event are as follows:
.A2 a result of several occurrences of RWST level transmitter and sense line freezing, Design Change Request 1399 was initiated in December 1981 requesting that adequate ,
freeze protection be provided.
NRC Peren 308A (649)
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In July 1982, Engineering Change Notice'(ECN) 5653 (Work Plan 10095) was_ approved to !
install strip heaters and control thermostats inside the RWST level transmitter anclosures (1,.2-LT-63-50, 51, 52,.and 53). In addition, heat tracing and insulation was upgraded for the sense lines and enclosures.
On March 17, 1988, Condition Adverse to Quality Report (CAQR) SQP 880260 was written to
-document two problems associated with ECN 5653.' Problem it Based on Quality
- Information Release NEB 87276, which reported th'e results of the analysis that was documented in calculation SQN-APS2-039, the temperature inside the level transmitter cnclosure could reach as high as 315 degrees F should the thermostats / heaters fail to da-energize. This exceeded the 140 degrees F maximum ambient temperature rating of the 1svel transmitters. Problem 2 No documentation had been found'to indicate that this equipment was qualified for applications involving Class 1E equipment. These problems ware also documented as Design Baseline Verification Program Punchlist Items 8885 .i and 9684. l 1
To resolve the CAQR, Design Change Notices (DCNs) M01138A and M01139A were issued on I Ssptember 21, 1989, to remove electrical power to the thermostats and heaters installed i under ECN 5653. The DCNs also qualified the thermostats and heaters to position !
retention requirements because they were not removed as part of the DCNs. Because the hsaters and thermostats were no longer a heat source and seismic qualification was demonstrated, both of the problems stated above were resolved. Calculation SQN-APS2-039 l was referenced in these DCNs to provide' assurance that the level transmitters would '
function at low temperatures.
During the independent qualified reviewer (IQR) review of the workplan for DCNs M01138A and M01139A, questions were again raised concerning the potential.for freezing of the sense lines. NE resolved this comment with the IQR, and the DON was implemented; however, NE agreed to later perform calculation SQN-SQS2-0101, which confirmed that sense line freezing would occur. Calculation SQN-SQS2-0101 was completed on November 13, 1989, and an action item was placed on the Plan of the Day (POD) meeting agenda to procure and install qualified 1E thermostats._ The purchase request was to be initiated by December 15, 1989, with installation anticipated for mid-January. These e proposed dates were considered acceptable by personnel who anticipated that extreme weather would not occur until the ' late January or early February time frame. Therefore,
. low temperature protection was not provided, and, as a result, the level transmitters began to fail at 0357 on December 16, 1989, l i
CAUSE OF EVENT RWST' (
The root cause of this event is attributed to NE misapplying the results of calculation SQN-APS2-039. The conditions _and assumptions in this calculation were to determine the maximum internal enclosure temperature (based on varying outside temperatures), rather than the minimum. However, the information was incorrectly interpreted by personnel utilizing the calculation.
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In addition, personnel preparing DCNs 1138 and 1139 incorrectly assumed that the review performed by the personnel of the discipline that prepared the calculation for. the safety evaluation for these DCNs served as the inter-disciplinary technical interface review required in accordance with Nuclear Engineering Procedure (NEP)'5.2.
Although the problem of possible freezing of the-sense lines and transmitters was' identified _in the POD meeting on October 26, 1989, as an action item, it was not given proper management attention to prevent this occurrence. Site personnel involved with this issue failed to initiate a CAQR when it was confirmed that-an inadequate design change had been implemented because a calculation was misapplied.
1 Main Steam Valve Vaults The root cause of Pressure Transmitter 1-PT-1-9A freezing was inadequate consideration i of additional freeze protection requirements during design changes to increase l vsntilation flow. As a result of these design changes, freezing was considered and cddressed in procedure GOI-6H, but it was not anticipated that there would be freezing-problems in the main steam valve vaults during power operational _ modes.
Auxiliary Building (Exterior) l' The root cause of Flow Transmitter 2-FT-3-90A freezing is attributed to-insulation not k
~bsing in accordance with design drawings, i.e., wrong type of insulation. I ANALYSIS OF EVENT !
L This event is being reported in accordance with 10 CFR 50.73, paragraph a.2.i.b. as an operation prohibited by the plant technical specifications.
RWST The primary function of the RWST is to provide a source of borated water to the cmergency core cooling system during a loss of_ reactor coolant condition. The purpose j of the-level transmitters is to provide RWST level indication and automatic transfer of stfety injection suction from RWST to the containment sump upon low RWST level-(with- j concurrent minimum sump level) after safety injection signal actuation. If these transmitter failures had occurred concurrent with a loss of coolant accident, the result could have been a failure of automatic transfer of safety injection auction from RWST to the containment sump and could result in a loss of flow and possible damage to pumps. .
Indication of the failure of these transmitters was inanediately noticed by the unit '
operators, and operators took appropriate actions.
Main Steam Valve Vault and Auxiliary Building (Exterior) '
The instrument failures, which occurred in the east main steam valve vault and the exterior of the auxiliary building, are part of the steam / feed flow regulating logic.
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-ANALYSIS OF EVENT (Continued), ;
Failure of the main ~ steam pressure transmitter (1-PT-1-9A) in the high direction is away Co n the safety limits (low pressure) that would prevent sensing a requirement for a. ;
d ly action. The' low pressure.is one of the two possible signals coincident with high steam flow delta P that initiates a steam line isolation and safety injection.
1-PT-1-9A provides an input signal to the 1-FT-1-10A flow transmitter. Operations tripped the appropriate bistables ensuring the operable Transmitter 1-PT-1-9B would datect and perform the required safety action. '
Failure of the main feed Flow Transmitter (2-FT-3-90A) high direction also moved the !
indication away from safety limits. Feed flow is-used along with steam flow to ;
determine mismatch (steam flow greater than. feed flow) coincident with low-steam gsnerator (S/G) level to initiate a reactor-trip. Operations tripped the appropriate bistables thus ensuring safety.- The transmitter was being used for Loop 3 S/G control. ,
Failure of the transmitter in the high direction caused the control system to reduce flow to Loop 3. Operator intervention save.d a S/G low-level reactor trip and recovered the S/G 1evel. Operations then placed control in a reliable. flow loop.
l CORRECTIVE ACTION l'
Immediate Corrective Action ,
Immediate corrective actions taken for the RWST consisted of obtaining discretionary ;
enforcement to extend operating in LCO 3.0.3, erecting enclosures, installing heating within enclosures, issuing night orders containing provisions to ensure adequate RWST' water levels exist and to provide revised operational requirements for Emergency Procedure ES-1.2, and recalibrating the transmitters. TACF 0-89-69-063 was initiated to
- l. rainstall power to the enclosure heaters and thermostats for the-level transmitters.
Operations Section Letters Administrative 99 was revised to require operator varification to detect potential failures every four hours.
- Immediate corrective actions taken for the main steam valve. vault consisted of issuing.
TACF 0-89-7L-400 to install plastic sheeting over the blow-out panels in the east and
' wast main steam valve vaults to prevent the loss of internal heating. Periodic-monitoring was initiated for. temperature verif f :ation' in the main steam valve . vaults (once each shift).
Immediate corrective actions taken for the auxiliary building (exterior) consisted of issuing Work Request B793481 to repair the insulation, install a plastic sheeting tent and heater around the transmitter, and to blowdown and recalibrate the transmitter.
Long-Term Corrective Action 1.- Immediate action was taken by the Work Control Group to revise the POD agenda to readily identify and prioritize items that may have an immediate or significant .!
affect on plant operability.
- NIC Form NSA SSSI - 6
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OF MANAGEMENT AND BUDGET,W ASHINGTON.DC 20603. x 9 ACILITY WAast 41. DOC 8tET NunSSR 12).. '
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0l0 0l7 0F 0 l8 text nr . e .as wmac r asnawim j CORRECTIVE ACTION (Continued) 2.- Field-DCNs 1858A and 1859A have been issued to add qualified 1E thermostats and to reconnect the heaters. The field implementation will be completed by January 31, 1990.
- 3. The insulation on the seven sense lines identical'to 2-FT-3-90A will be verf.fied.to be in accordance with the design drawings by January 26,~1990.
- 4. An investigation will be performed to determine how the improper insulation was installed on 2-FT-3-90A by March 15, 1990. ,
- 5. NE will revise the appropriate procedures by February 28, 1990, to require that-NE personnel utilizing existing design input (i.e., calculations) from another discipline to support the issuance of design output = documents shall obtain an inter-disciplinary technical interface review in accordance with NEP 5.2 and-'shall require their concurrence on the involved DCN cover sheet prior to issuing the 4 output.
- 6. To address the issue that a CAQR was not initiated when calculation SQN-SQS2-0101
( identified that the RWST sense. lines would freeze, each discipline lead engineer shall instruct their employees on the importance of identifying conditions adverse to quality when deficiencies are first noted so that proper and: timely corrective action can be taken. Appropriate disciplinary. action will be taken'for the individuals concerned with this event. .These actions will be completed by:
February 16, 1990.
- 7. Sense lines located close to the openings in the valve vaults shall.be evaluated for rerouting or installation of permanent insulation.- The-evaluation-results will be implemented by November 1 1990.
ADDITIONAL INFORMATION 1
There have been nine previous LERs reported as a result of freezing instrument lines (SQN 50-327/80-202,80-206, 81-003,81-004, 81-154,85-006, 50-328/82-101,82-013, and 83-006. Previous corrective actions were not effective because of the reasons identified in this report. There had been no LERs written after the heat-trace was added to the RWST instrument lines.
COMMITMENTS '
- 1. Field-DCNs 1858A and 1859A have been issued to add qualified 1E thermostats and reconnect the heaters. The field implementation will be completed by January 31,
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' COMMITMENTS (Continued)
- 2. NE will revise the appropriate procedures by February 28, 1990, to require that NE personnel utilizing existing design input (i.e., calculations) from another discipline to support the issuance of design output documents shall obtain an inter-disciplinary technical interf ace review in accordance with NEP 5.2 and shall require their concurrence on the involved DCN cover sheet prior to issuing the output.
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- 3. To address the issue-that a CAQR was not initiated when calculation SQN-SQS2-0101 identified that the RWST sense lines would freeze, each discipline lead engineer shall instruct.their employees on the importance of identifying conditions adverse to quality when deficiencies are first noted so .that proper and timely corrective, action can be taken. Appropriate disciplinary action will be taken foi the individuals concerned with this event. These actions will'be completed by February 16, 1990. ~
1 4 Sense lines located close to the openings in the-valve vaults shall be evaluated for rerouting or installation of permanent insulation. The evaluation results-will be implemented by November 1, 1990.
- 5. The insulation on the seven sense lines identical to 2-FT-3-90A will be verified to be in accordance with the design drawings by January 26.-1990.
- 6. An investigation will be performed to determine how the improper insulation was installed on 2-FT-3-90A by March 15, 1990. ;
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