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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML18066A6271999-09-0202 September 1999 LER 98-011-01:on 981217,inadequate Lube Oil Collection Sys for Primary Coolant Pumps Was Noted.Caused by Design Change Not Containing Appropriate Level of Rigor.Exemption from 10CFR50,App R Was Requested.With 990902 Ltr ML18066A6221999-08-20020 August 1999 LER 99-002-00:on 990722,TS Surveillance Was Not Completed within Specified Frequency.Caused by Failure to Incorporate Revised Frequency Into Surveillance Schedule in Timely Manner.Verified Implementation.With 990820 Ltr ML18066A3781999-01-20020 January 1999 LER 98-013-00:on 981222,safeguards Transfer Tap Changer Failure Caused Inadvertant DG Start.Caused by Failed Motor Contactor.Contactor Was Replaced.With 990120 Ltr ML18068A4851998-10-29029 October 1998 LER 97-011-01:on 971012,starting of Primary Coolant Pump with SG Temps Greater than Cold Leg Temps Occurred.Caused by Inadequate Procedures & Operator Decision.Sop Used for Starting Primary Coolant Pump Enhanced ML18066A2831998-08-18018 August 1998 LER 98-010-00:on 980721,reactor Manually Tripped.Caused by Failure of Coupling Which Drives Feedwater Pump Main Lube Oil Pump.Main Lube Oil Pump Coupling & Associated Components Replaced & Satisfactorily Tested ML18066A2261998-06-30030 June 1998 LER 98-009-00:on 980531,small Pinhole Leak Found on One of Welds,During Leak Test Following Replacement of Pcs Sample Isolation Valves.Caused by Welder Error.Leaking Welds Repaired ML18066A1781998-06-0909 June 1998 LER 98-008-00:on 980511,noted That Procedure Did Not Fully Satisfy Requirement to Test High Startup Rate Trip Function. Caused by Misunderstanding of Testing Requirements.Revised TS Surveillance Test Procedure & Reviewed Other Procedures ML18065B2451998-05-13013 May 1998 LER 98-007-00:on 980413,HPIS Sys Was Noted Inoperable During TS Surveillance Test.Caused by Performance of Flawed Procedure.Operators & Engineers Will Be Trained to Improve Operational Decision Making Through Resources & Knowledge ML18065B1151997-12-0909 December 1997 LER 97-013-00:on 971110,failure to Closure Test Two Check Valves Resulted in Violation of TS 6.5.7 Occurred.Caused by Close Function for Check Valves.Check Valves Tested to Confirm Proper Closure Capability ML18067A7751997-11-11011 November 1997 LER 97-011-00:on 971012,primary Coolant Pump Was Started W/Sg Temperatures Greater than Cold Leg Temperature.Caused by Inadequate Procedures & Operator Decision Making.Critique of Event Conducted W/Operators Involved ML18067A7581997-10-30030 October 1997 LER 97-010-00:on 970930,determined That Inadequacy in App R Analysis Resulted in Condition Outside Design Basis of Plant.Caused by Missing Cable in Circuit & Raceway Schedule. Developed New Evaluation Re ASD Valves Validation ML18067A7461997-10-23023 October 1997 LER 97-009-00:on 970923,discovered Procedure Weakness Re Implementation of App R Shutdown Methodology.Caused by Human Error.Revised Off-Normal Procedure ONP-25.2, Alternate Safe Shutdown Procedure. ML18067A7191997-10-10010 October 1997 LER 97-008-00:on 970912,spurious Valve Operation Could Result in Loss of Shutdown Capabilities Per 10CFR50,App R, Section Iii.L,Was Discovered.Caused by Failure to Validate Info from App R.Design Bases for SW Backup Reviewed ML18067A6951997-09-24024 September 1997 LER 97-007-00:on 970826,discovered Inadequate Testing of DG Sequencer Control Relay Contacts.Caused by Oversight on Part of Personnel Involved in Installation of Facility Change FC-800.Tested 106D-1/XL & 106D-2/XL Relay Contacts ML18067A5651997-06-0303 June 1997 LER 96-013-01:on 961115,DC Breaker Failed During Testing for as-found Trip Setting.Failure Caused by Oversight within Preventive Maint Program.Breaker Was Replaced & Tested ML18067A5461997-05-12012 May 1997 LER 97-006-00:on 970412,overtime Limits Were Exceeded for Radiation Protection Technicians.Caused by Inadequate Design,Review & Proper Verifications of Overtime Work Schedule.Communicate Overtime Limitation Responsibilities ML18067A4431997-03-24024 March 1997 LER 97-004-00:on 970221,trip of High Pressure Safety Injection Pump Occurred While Filling Safety Injection Tank Resulting in TS Violation.Caused by Particle Lodged Between Surface of Indication disk.Y-phase Relay Was OOS ML18067A4391997-03-21021 March 1997 LER 97-005-00:on 961220,operation of Plant Outside Design Basis Occurred Due to an Unacceptable Repair on Main Steam Isolation Valves.Pipe Plugs Permanently Repaired ML18067A4401997-03-21021 March 1997 LER 97-003-00:on 961101,four Piping Lines Were Determined to Be Potentially Susceptible to Pressurization Due to Containment Temperature Increase During an Accident.Cac Discharge Piping Will Be verified.W/970321 Ltr ML18066A8931997-02-21021 February 1997 LER 97-002-00:on 970123,failure to Meet TSs 4.5.2d(1)(b) for Testing of Emergency Escape Airlock Occurred.Caused by Missed Surveillance.Emergency Escape Air Lock Testing Was Completed & Declared operable.W/970221 Ltr ML18066A8751997-02-0505 February 1997 LER 97-001-00:on 970106,TAVE Temp Dropped Below Minimum Temp for Criticality.Caused by Control Rod Withdrawal Rate to Increase Power Not Sufficient to Match Increase in Steam. Turbine Bypass Valve Actuator repaired.W/970205 Ltr ML18066A8041996-12-23023 December 1996 LER 96-014-00:on 961124,class 1E Raychem Cable Splices Were Installed Incorrectly.Caused by Incorrectly Made Electrical Splices.Total of 270 Splices Have Been Replaced within Containment ML18066A7831996-12-16016 December 1996 LER 96-013-00:on 961115,DC Breaker Failure During Testing for as-found Trip Setting Occurred.Cause Under Investigation.All molded-case Circuit Breakers in DC Distribution Panels Were Replaced ML18065A9951996-10-0404 October 1996 LER 96-002-01:on 960116,initiated TS Required Shutdown Due to Safeguards Cable Fault.Both Sets (Six Cables) of Cables Were Replaced & Installed Through Turbine Generator Bldg ML18065A9171996-09-0909 September 1996 LER 95-012-00:on 960809,TS Violation Occurred,Due to No Senior Reactor Operator in Cr.Caused by Extensive Remodeling.Cr Remodeling completed.W/960909 Ltr ML18065A8961996-08-29029 August 1996 LER 96-011-00:on 960730,CR Continuous Air Monitor Alarm Setpoint Improperly Established.Caused by Failure to Utilize Mod Process in 1988 Leading to Failure to Properly Select & Calibrate Instruments ML18065A8811996-08-20020 August 1996 LER 96-005-01:on 960207,determined Fuse on Main Supply to Two Safety Related DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Lack of Thorough Associated Circuits Analysis.Supply Fuse to Panels Replaced ML18065A8741996-08-16016 August 1996 LER 96-010-00:on 960717,high Pressure Safety Injection Pump Tripped While Filling Safety Injection Tank.Caused by Faulty 150/151Y-207 Time Overcurrent Relay.All Similar Relays in Time Overcurrent Application Have Been Inspected ML18065A8651996-08-12012 August 1996 LER 96-009-00:on 960712,identified Penetration Seal Deficiency on Fire Barriers Caused by Failure to Perform & Document Comprehensive Fire Barrier Evaluation.Developed Basis document.W/960812 Ltr ML18065A8601996-08-0202 August 1996 LER 96-006-01 on 960207,discovered Limits of Design Analysis Could Have Been Violated.Subsequent Tests & Analyses Facility Did Not Exceed Basis.Operating Procedures Have Been Revised to Treat 2530 Megawatts Limit as Absolute Limit ML18065A8321996-08-0101 August 1996 LER 96-003-01:on 960115,alternate Shutdown Panel Inverter Resulted in Unavailability of Panel.Replaced Defective Inverter Alarm Logic Board ML18065A7691996-06-12012 June 1996 LER 96-008-00:on 960513,fire Door Not Maintained Open in Accordance W/Design Basis.Cause Under Investigation. Engineering Evaluation Performed & Revised Documents, Surveillance & Test procedures.W/960612 Ltr ML18065A6901996-05-0101 May 1996 LER 95-001-01:on 950302,malfunction of Left Channel DBA Sequencer Resulted in Inadvertent Actuation of Left Channel Safeguards Equipment.Replaced microprocessor.W/960501 Ltr ML18065A6681996-04-22022 April 1996 LER 96-007-00:on 960321,inadequate Emergency Lighting & Ventilation in post-fire Safe Shutdown Areas.Caused by App R Program Documentation Insufficient to Demonstrate Regulatory Compliance.Lighting modified.W/960422 Ltr ML18065A5721996-03-11011 March 1996 LER 96-006-00:on 960207,average Reactor Power Level Exceeded License Limit Due to Insufficient Procedural Guidance. GOP-12 Revised to Treat 2,530 Mwt Limit as Absolute Limit Requiring Immediate Corrective Action If Exceeded ML18065A5261996-03-0101 March 1996 LER 96-005-00:on 960202,fuse on Main Supply to Two SR DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Inadequate Electrical/App R Design Review.Implemented Hourly Fire tours.W/960301 Ltr ML18065A5111996-02-19019 February 1996 LER 94-012-02:on 940427,determined That Internal Ground in Thermal Margin Monitor Causes Nonconformance W/Rps Design Basis.Incorporated RPS Failure Modes & Effects Analysis in Plant DBD.W/960219 Ltr ML18065A5061996-02-19019 February 1996 LER 96-004-00:on 960118,SIS Disabled W/Primary Coolant Sys Greater than 300 F.Caused by Personnel Error.Permanent Maint Procedure to Disable/Enable SIS Actuation on Low Pressurizer Pressure Will Be Revised to Align W/Ts ML18065A5021996-02-15015 February 1996 LER 96-003-00:on 960115,technicians Found Low Voltage cut- Off for Alternate Shutdown Panel Inverter Set That Resulted in Unavailability of Panel.Caused by Inadequate Post Mod. Readjusted Set Point to Minimum setting.W/960215 Ltr ML18065A4581996-01-31031 January 1996 LER 96-001-00:on 960103,failed to Test Duplicate Equipment. Caused by STS No Longer Containing Requirement for cross- Train Testing of Duplicate Components.Will Submit Request to Delete Subj Requirements from TS.W/960131 Ltr ML18065A4421996-01-19019 January 1996 LER 95-016-00:on 951226,did Not Analyze Primary Coolant Samples within 72 H.Caused by Belief Acceptability to Save Pcs Samples for Choride Analysis Past 72 H.Counseled Chemistry Supervision.W/960119 Ltr ML18065A4041996-01-15015 January 1996 LER 95-014-00:on 950119,PCP Oil Collection Deficiencies Created by FC-860 Piping Mod.Caused by Inadequate DBD for Sys & Lack of Review by Experienced Fire Protection Personnel.Updated Design Basis documentation.W/960115 Ltr ML18065A3291995-12-0404 December 1995 LER 95-013-00:on 951103,circuit Fuse Coordination Deficiency Which Affects App R Safe Shutdown Equipment Noted.Design of Fuse Coordination in Potential Transformer Circuits Will Be Evaluated & Modified as required.W/951204 Ltr ML18065A2361995-11-0202 November 1995 LER 95-012-00:on 950701,discovered Unqualified Electrical Connection in Containment SW Outlet Valve Controller.Caused by Failure of Assigned Engineers to Available Info.Replaced Wire Nuts W/Inline Butt connections.W/951102 Ltr ML18065A2051995-10-20020 October 1995 LER 95-008-01:on 950728,discovered That None of Four Containment High Pressure Channels Would Initiate Reactor Trip Due to Programmatic Deficiencies.Administrative Procedure (AP) 9.44,AP 9.45 & AP 10.44 Will Be Revised ML18065A0841995-09-18018 September 1995 LER 95-011-00:on 950817,CR 40 Withdrawal Occurred When Given Insertion Signal Due to skill-based Error in Crimping & Removing Foreign Matl from CRDM Motor Connection Box.Crd Package replaced.W/950918 Ltr ML18065A0681995-09-14014 September 1995 LER 95-010-00:on 950815,ESFA Resulted in Manual Rt Following Isolation of Pcs.Replaced Failed Instrument Line ML18065A0651995-09-0808 September 1995 LER 95-009-00:on 950728,discovered Lack of Procedural Guidance for Pump Repair Following Fire.Proposed Use of Power Supply Breaker Did Not Adequately Address Effect of Loss of Control Power.Performed Independent Assessment ML18064A8781995-08-28028 August 1995 LER 95-008-00:on 950728,discovered During Design Change Testing That None of Four Containment High Pressure Channels Would Initiate Rt.Caused by Programmatic Deficiencies. Reviewed Selected Tests & Mods from Recent Refueling Outage ML18064A8831995-08-21021 August 1995 LER 95-007-00:on 950720,discovered That 12 Instrument Loops Had V-bolted Type Qualified Cable Splices Connected to Wires W/Exposed Kapton Insulation.Caused by Human Error.All V- Bolted Splices Replaced w/in-line design.W/950821 Ltr 1999-09-02
[Table view] Category:RO)
MONTHYEARML18066A6271999-09-0202 September 1999 LER 98-011-01:on 981217,inadequate Lube Oil Collection Sys for Primary Coolant Pumps Was Noted.Caused by Design Change Not Containing Appropriate Level of Rigor.Exemption from 10CFR50,App R Was Requested.With 990902 Ltr ML18066A6221999-08-20020 August 1999 LER 99-002-00:on 990722,TS Surveillance Was Not Completed within Specified Frequency.Caused by Failure to Incorporate Revised Frequency Into Surveillance Schedule in Timely Manner.Verified Implementation.With 990820 Ltr ML18066A3781999-01-20020 January 1999 LER 98-013-00:on 981222,safeguards Transfer Tap Changer Failure Caused Inadvertant DG Start.Caused by Failed Motor Contactor.Contactor Was Replaced.With 990120 Ltr ML18068A4851998-10-29029 October 1998 LER 97-011-01:on 971012,starting of Primary Coolant Pump with SG Temps Greater than Cold Leg Temps Occurred.Caused by Inadequate Procedures & Operator Decision.Sop Used for Starting Primary Coolant Pump Enhanced ML18066A2831998-08-18018 August 1998 LER 98-010-00:on 980721,reactor Manually Tripped.Caused by Failure of Coupling Which Drives Feedwater Pump Main Lube Oil Pump.Main Lube Oil Pump Coupling & Associated Components Replaced & Satisfactorily Tested ML18066A2261998-06-30030 June 1998 LER 98-009-00:on 980531,small Pinhole Leak Found on One of Welds,During Leak Test Following Replacement of Pcs Sample Isolation Valves.Caused by Welder Error.Leaking Welds Repaired ML18066A1781998-06-0909 June 1998 LER 98-008-00:on 980511,noted That Procedure Did Not Fully Satisfy Requirement to Test High Startup Rate Trip Function. Caused by Misunderstanding of Testing Requirements.Revised TS Surveillance Test Procedure & Reviewed Other Procedures ML18065B2451998-05-13013 May 1998 LER 98-007-00:on 980413,HPIS Sys Was Noted Inoperable During TS Surveillance Test.Caused by Performance of Flawed Procedure.Operators & Engineers Will Be Trained to Improve Operational Decision Making Through Resources & Knowledge ML18065B1151997-12-0909 December 1997 LER 97-013-00:on 971110,failure to Closure Test Two Check Valves Resulted in Violation of TS 6.5.7 Occurred.Caused by Close Function for Check Valves.Check Valves Tested to Confirm Proper Closure Capability ML18067A7751997-11-11011 November 1997 LER 97-011-00:on 971012,primary Coolant Pump Was Started W/Sg Temperatures Greater than Cold Leg Temperature.Caused by Inadequate Procedures & Operator Decision Making.Critique of Event Conducted W/Operators Involved ML18067A7581997-10-30030 October 1997 LER 97-010-00:on 970930,determined That Inadequacy in App R Analysis Resulted in Condition Outside Design Basis of Plant.Caused by Missing Cable in Circuit & Raceway Schedule. Developed New Evaluation Re ASD Valves Validation ML18067A7461997-10-23023 October 1997 LER 97-009-00:on 970923,discovered Procedure Weakness Re Implementation of App R Shutdown Methodology.Caused by Human Error.Revised Off-Normal Procedure ONP-25.2, Alternate Safe Shutdown Procedure. ML18067A7191997-10-10010 October 1997 LER 97-008-00:on 970912,spurious Valve Operation Could Result in Loss of Shutdown Capabilities Per 10CFR50,App R, Section Iii.L,Was Discovered.Caused by Failure to Validate Info from App R.Design Bases for SW Backup Reviewed ML18067A6951997-09-24024 September 1997 LER 97-007-00:on 970826,discovered Inadequate Testing of DG Sequencer Control Relay Contacts.Caused by Oversight on Part of Personnel Involved in Installation of Facility Change FC-800.Tested 106D-1/XL & 106D-2/XL Relay Contacts ML18067A5651997-06-0303 June 1997 LER 96-013-01:on 961115,DC Breaker Failed During Testing for as-found Trip Setting.Failure Caused by Oversight within Preventive Maint Program.Breaker Was Replaced & Tested ML18067A5461997-05-12012 May 1997 LER 97-006-00:on 970412,overtime Limits Were Exceeded for Radiation Protection Technicians.Caused by Inadequate Design,Review & Proper Verifications of Overtime Work Schedule.Communicate Overtime Limitation Responsibilities ML18067A4431997-03-24024 March 1997 LER 97-004-00:on 970221,trip of High Pressure Safety Injection Pump Occurred While Filling Safety Injection Tank Resulting in TS Violation.Caused by Particle Lodged Between Surface of Indication disk.Y-phase Relay Was OOS ML18067A4391997-03-21021 March 1997 LER 97-005-00:on 961220,operation of Plant Outside Design Basis Occurred Due to an Unacceptable Repair on Main Steam Isolation Valves.Pipe Plugs Permanently Repaired ML18067A4401997-03-21021 March 1997 LER 97-003-00:on 961101,four Piping Lines Were Determined to Be Potentially Susceptible to Pressurization Due to Containment Temperature Increase During an Accident.Cac Discharge Piping Will Be verified.W/970321 Ltr ML18066A8931997-02-21021 February 1997 LER 97-002-00:on 970123,failure to Meet TSs 4.5.2d(1)(b) for Testing of Emergency Escape Airlock Occurred.Caused by Missed Surveillance.Emergency Escape Air Lock Testing Was Completed & Declared operable.W/970221 Ltr ML18066A8751997-02-0505 February 1997 LER 97-001-00:on 970106,TAVE Temp Dropped Below Minimum Temp for Criticality.Caused by Control Rod Withdrawal Rate to Increase Power Not Sufficient to Match Increase in Steam. Turbine Bypass Valve Actuator repaired.W/970205 Ltr ML18066A8041996-12-23023 December 1996 LER 96-014-00:on 961124,class 1E Raychem Cable Splices Were Installed Incorrectly.Caused by Incorrectly Made Electrical Splices.Total of 270 Splices Have Been Replaced within Containment ML18066A7831996-12-16016 December 1996 LER 96-013-00:on 961115,DC Breaker Failure During Testing for as-found Trip Setting Occurred.Cause Under Investigation.All molded-case Circuit Breakers in DC Distribution Panels Were Replaced ML18065A9951996-10-0404 October 1996 LER 96-002-01:on 960116,initiated TS Required Shutdown Due to Safeguards Cable Fault.Both Sets (Six Cables) of Cables Were Replaced & Installed Through Turbine Generator Bldg ML18065A9171996-09-0909 September 1996 LER 95-012-00:on 960809,TS Violation Occurred,Due to No Senior Reactor Operator in Cr.Caused by Extensive Remodeling.Cr Remodeling completed.W/960909 Ltr ML18065A8961996-08-29029 August 1996 LER 96-011-00:on 960730,CR Continuous Air Monitor Alarm Setpoint Improperly Established.Caused by Failure to Utilize Mod Process in 1988 Leading to Failure to Properly Select & Calibrate Instruments ML18065A8811996-08-20020 August 1996 LER 96-005-01:on 960207,determined Fuse on Main Supply to Two Safety Related DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Lack of Thorough Associated Circuits Analysis.Supply Fuse to Panels Replaced ML18065A8741996-08-16016 August 1996 LER 96-010-00:on 960717,high Pressure Safety Injection Pump Tripped While Filling Safety Injection Tank.Caused by Faulty 150/151Y-207 Time Overcurrent Relay.All Similar Relays in Time Overcurrent Application Have Been Inspected ML18065A8651996-08-12012 August 1996 LER 96-009-00:on 960712,identified Penetration Seal Deficiency on Fire Barriers Caused by Failure to Perform & Document Comprehensive Fire Barrier Evaluation.Developed Basis document.W/960812 Ltr ML18065A8601996-08-0202 August 1996 LER 96-006-01 on 960207,discovered Limits of Design Analysis Could Have Been Violated.Subsequent Tests & Analyses Facility Did Not Exceed Basis.Operating Procedures Have Been Revised to Treat 2530 Megawatts Limit as Absolute Limit ML18065A8321996-08-0101 August 1996 LER 96-003-01:on 960115,alternate Shutdown Panel Inverter Resulted in Unavailability of Panel.Replaced Defective Inverter Alarm Logic Board ML18065A7691996-06-12012 June 1996 LER 96-008-00:on 960513,fire Door Not Maintained Open in Accordance W/Design Basis.Cause Under Investigation. Engineering Evaluation Performed & Revised Documents, Surveillance & Test procedures.W/960612 Ltr ML18065A6901996-05-0101 May 1996 LER 95-001-01:on 950302,malfunction of Left Channel DBA Sequencer Resulted in Inadvertent Actuation of Left Channel Safeguards Equipment.Replaced microprocessor.W/960501 Ltr ML18065A6681996-04-22022 April 1996 LER 96-007-00:on 960321,inadequate Emergency Lighting & Ventilation in post-fire Safe Shutdown Areas.Caused by App R Program Documentation Insufficient to Demonstrate Regulatory Compliance.Lighting modified.W/960422 Ltr ML18065A5721996-03-11011 March 1996 LER 96-006-00:on 960207,average Reactor Power Level Exceeded License Limit Due to Insufficient Procedural Guidance. GOP-12 Revised to Treat 2,530 Mwt Limit as Absolute Limit Requiring Immediate Corrective Action If Exceeded ML18065A5261996-03-0101 March 1996 LER 96-005-00:on 960202,fuse on Main Supply to Two SR DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Inadequate Electrical/App R Design Review.Implemented Hourly Fire tours.W/960301 Ltr ML18065A5111996-02-19019 February 1996 LER 94-012-02:on 940427,determined That Internal Ground in Thermal Margin Monitor Causes Nonconformance W/Rps Design Basis.Incorporated RPS Failure Modes & Effects Analysis in Plant DBD.W/960219 Ltr ML18065A5061996-02-19019 February 1996 LER 96-004-00:on 960118,SIS Disabled W/Primary Coolant Sys Greater than 300 F.Caused by Personnel Error.Permanent Maint Procedure to Disable/Enable SIS Actuation on Low Pressurizer Pressure Will Be Revised to Align W/Ts ML18065A5021996-02-15015 February 1996 LER 96-003-00:on 960115,technicians Found Low Voltage cut- Off for Alternate Shutdown Panel Inverter Set That Resulted in Unavailability of Panel.Caused by Inadequate Post Mod. Readjusted Set Point to Minimum setting.W/960215 Ltr ML18065A4581996-01-31031 January 1996 LER 96-001-00:on 960103,failed to Test Duplicate Equipment. Caused by STS No Longer Containing Requirement for cross- Train Testing of Duplicate Components.Will Submit Request to Delete Subj Requirements from TS.W/960131 Ltr ML18065A4421996-01-19019 January 1996 LER 95-016-00:on 951226,did Not Analyze Primary Coolant Samples within 72 H.Caused by Belief Acceptability to Save Pcs Samples for Choride Analysis Past 72 H.Counseled Chemistry Supervision.W/960119 Ltr ML18065A4041996-01-15015 January 1996 LER 95-014-00:on 950119,PCP Oil Collection Deficiencies Created by FC-860 Piping Mod.Caused by Inadequate DBD for Sys & Lack of Review by Experienced Fire Protection Personnel.Updated Design Basis documentation.W/960115 Ltr ML18065A3291995-12-0404 December 1995 LER 95-013-00:on 951103,circuit Fuse Coordination Deficiency Which Affects App R Safe Shutdown Equipment Noted.Design of Fuse Coordination in Potential Transformer Circuits Will Be Evaluated & Modified as required.W/951204 Ltr ML18065A2361995-11-0202 November 1995 LER 95-012-00:on 950701,discovered Unqualified Electrical Connection in Containment SW Outlet Valve Controller.Caused by Failure of Assigned Engineers to Available Info.Replaced Wire Nuts W/Inline Butt connections.W/951102 Ltr ML18065A2051995-10-20020 October 1995 LER 95-008-01:on 950728,discovered That None of Four Containment High Pressure Channels Would Initiate Reactor Trip Due to Programmatic Deficiencies.Administrative Procedure (AP) 9.44,AP 9.45 & AP 10.44 Will Be Revised ML18065A0841995-09-18018 September 1995 LER 95-011-00:on 950817,CR 40 Withdrawal Occurred When Given Insertion Signal Due to skill-based Error in Crimping & Removing Foreign Matl from CRDM Motor Connection Box.Crd Package replaced.W/950918 Ltr ML18065A0681995-09-14014 September 1995 LER 95-010-00:on 950815,ESFA Resulted in Manual Rt Following Isolation of Pcs.Replaced Failed Instrument Line ML18065A0651995-09-0808 September 1995 LER 95-009-00:on 950728,discovered Lack of Procedural Guidance for Pump Repair Following Fire.Proposed Use of Power Supply Breaker Did Not Adequately Address Effect of Loss of Control Power.Performed Independent Assessment ML18064A8781995-08-28028 August 1995 LER 95-008-00:on 950728,discovered During Design Change Testing That None of Four Containment High Pressure Channels Would Initiate Rt.Caused by Programmatic Deficiencies. Reviewed Selected Tests & Mods from Recent Refueling Outage ML18064A8831995-08-21021 August 1995 LER 95-007-00:on 950720,discovered That 12 Instrument Loops Had V-bolted Type Qualified Cable Splices Connected to Wires W/Exposed Kapton Insulation.Caused by Human Error.All V- Bolted Splices Replaced w/in-line design.W/950821 Ltr 1999-09-02
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML18066A6901999-11-0101 November 1999 Rev 5 to Palisades Nuclear Plant Colr. ML18066A6761999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Palisades Nuclear Plant ML18066A6271999-09-0202 September 1999 LER 98-011-01:on 981217,inadequate Lube Oil Collection Sys for Primary Coolant Pumps Was Noted.Caused by Design Change Not Containing Appropriate Level of Rigor.Exemption from 10CFR50,App R Was Requested.With 990902 Ltr ML18066A6351999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Palisades Nuclear Plant ML18066A6771999-08-31031 August 1999 Operating Data Rept Page of MOR for Aug 1999 for Palisades Nuclear Plant ML18066A6221999-08-20020 August 1999 LER 99-002-00:on 990722,TS Surveillance Was Not Completed within Specified Frequency.Caused by Failure to Incorporate Revised Frequency Into Surveillance Schedule in Timely Manner.Verified Implementation.With 990820 Ltr ML18066A6061999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Palisades Nuclear Plant.With 990803 Ltr ML18066A5201999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Palisades Nuclear Plant.With 990702 Ltr ML18066A4841999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Palisades Nuclear Plant.With 990603 Ltr ML18066A6371999-04-30030 April 1999 Revised Monthly Operating Rept for Apr 1999 for Palisades Nuclear Plant ML18068A5941999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Palisades Nuclear Plant.With 990503 Ltr ML18066A4161999-04-0101 April 1999 Rev 4 to COLR, for Palisades Nuclear Plant ML18066A4501999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Palisades Nuclear Plant.With 990402 Ltr ML18066A4671999-03-31031 March 1999 Rev 0 to SIR-99-032, Flaw Tolerance & Leakage Evaluation Spent Fuel Pool Heat Exchanger E-53B Nozzle Palisades Nuclear Plant. ML18068A5351999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Palisades Nuclear Plant.With 990302 Ltr ML18066A3931999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Palisades Nuclear Plant.With 990202 Ltr ML18066A3781999-01-20020 January 1999 LER 98-013-00:on 981222,safeguards Transfer Tap Changer Failure Caused Inadvertant DG Start.Caused by Failed Motor Contactor.Contactor Was Replaced.With 990120 Ltr ML20206F6131998-12-31031 December 1998 1998 Consumers Energy Co Annual Rept. with ML18066A3651998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Palisades Nuclear Plant.With 990105 Ltr ML18066A3421998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Palisades Nuclear Plant.With 981202 Ltr ML18066A3301998-11-11011 November 1998 Part 21 Rept Re Potential Safety Hazard Associated with Wrist Pin Assemblies for FM-Alco 251 Engines at Palisades Nuclear Power Plant.Caused by Insufficient Friction Fit Between Pin & Sleeve.Supplier of Pin Will No Longer Be Used ML18068A4921998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for Palisades Nuclear Plant.With 981103 Ltr ML18068A4851998-10-29029 October 1998 LER 97-011-01:on 971012,starting of Primary Coolant Pump with SG Temps Greater than Cold Leg Temps Occurred.Caused by Inadequate Procedures & Operator Decision.Sop Used for Starting Primary Coolant Pump Enhanced ML18066A3181998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Palisades Nuclear Plant ML18066A2901998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for Palisades Nuclear Power Plant.With 980903 Ltr ML18066A3191998-08-31031 August 1998 Revised Monthly Operating Rept Data for Aug 1998 for Palisades Nuclear Plant ML18066A2831998-08-18018 August 1998 LER 98-010-00:on 980721,reactor Manually Tripped.Caused by Failure of Coupling Which Drives Feedwater Pump Main Lube Oil Pump.Main Lube Oil Pump Coupling & Associated Components Replaced & Satisfactorily Tested ML18066A2771998-08-13013 August 1998 Part 21 Rept Re Deficiency in CE Current Screening Methodology for Determining Limiting Fuel Assembly for Detailed PWR thermal-hydraulic Sa.Evaluations Were Performed for Affected Plants to Determine Effect of Deficiency ML20237E0301998-07-31031 July 1998 ISI Rept 3-3 ML18066A2701998-07-31031 July 1998 Monthly Operating Rept for July 1998 for Palisades Nuclear Plant.W/980803 Ltr ML18066A2311998-06-30030 June 1998 Monthly Operating Rept for June 1998 for Palisades Nuclear Plant ML18066A2261998-06-30030 June 1998 LER 98-009-00:on 980531,small Pinhole Leak Found on One of Welds,During Leak Test Following Replacement of Pcs Sample Isolation Valves.Caused by Welder Error.Leaking Welds Repaired ML18066A3061998-06-18018 June 1998 SG Tube Inservice Insp. ML20249C4951998-06-17017 June 1998 Rev 1 to EA-GEJ-98-01, Palisades Cycle 14 Disposition of Events Review ML18066A1781998-06-0909 June 1998 LER 98-008-00:on 980511,noted That Procedure Did Not Fully Satisfy Requirement to Test High Startup Rate Trip Function. Caused by Misunderstanding of Testing Requirements.Revised TS Surveillance Test Procedure & Reviewed Other Procedures ML18066A1711998-06-0101 June 1998 Part 21 Rept Re Impact of RELAP4 Excessive Variability on Palisades Large Break LOCA ECCS Results.Change in PCT Between Cycle 13 & Cycle 14 Does Not Constitute Significant Change Per 10CFR50.46 ML18066A1741998-05-31031 May 1998 Monthly Operating Rept for May 1998 for Palisades Nuclear Plant.W/980601 Ltr ML18066A2321998-05-31031 May 1998 Revised MOR for May 1998 for Palisades Nuclear Plant ML18068A4701998-05-31031 May 1998 Annual Rept of Changes in ECCS Models Per 10CFR50.46. ML18065B2451998-05-13013 May 1998 LER 98-007-00:on 980413,HPIS Sys Was Noted Inoperable During TS Surveillance Test.Caused by Performance of Flawed Procedure.Operators & Engineers Will Be Trained to Improve Operational Decision Making Through Resources & Knowledge ML18066A2331998-04-30030 April 1998 Revised MOR for Apr 1998 for Palisades Nuclear Plant ML18068A3461998-04-30030 April 1998 Monthly Operating Rept for Apr 1998 for Palisades Nuclear Plant.W/980501 Ltr ML18066A3411998-04-22022 April 1998 Rev 0 to EMF-98-013, Palisades Cycle 14:Disposition & Analysis of SRP Chapter 15 Events. ML18065B2071998-03-31031 March 1998 Monthly Operating Rept for Mar 1998 for Palisades Nuclear Plant.W/980403 Ltr ML20217C2741998-03-31031 March 1998 Independent Review - Is Consumers Energy Method (W Method) of Determining Palisades Nuclear Plant Best Estimate Fluence by Combining Transport Calculation & Dosimetry Measurements Technically Sound & Does It Meet Intent of Pts ML18066A2341998-03-31031 March 1998 Revised MOR for Mar 1998 for Palisades Nuclear Plant ML18068A3041998-02-28028 February 1998 Monthly Operating Rept for Feb 1998 for Palisades Nuclear Plant.W/980302 Ltr ML18066A2351998-02-28028 February 1998 Revised MOR for Feb 1998 for Palisades Nuclear Plant ML18065B1641998-02-0505 February 1998 Rev 0 to Regression Analysis for Containment Prestressing Sys at 25th Year Surveillance. ML18067A8211998-01-31031 January 1998 Monthly Operating Rept for Jan 1998 for Palisades Nuclear Plant.W/980203 Ltr 1999-09-30
[Table view] |
Text
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consumers Power* GB Slade General Manager P~WERINli MICHlliAN"S PIUlliRE55.
Palisades Nuclear Plant: 27780 Blue *star Memorial Highway, Coven, Ml 49043.
April 13, 1992 Nu cl ear Regulatory Commi ss. ion
. DOCKET 50-255 - LICENSE DPR PALISADES PLANT LICENSEE EVENT REPORT 92-02l~LOSS OF CONTAINMENT INTEGRITY DURING REFUELING DUE TO SIMULTANEOUS OPENING OF SYSTEM BOUNDARIES Licensee Event Report (LER)92-021 is attached. This event is reportable to the NRC in accordance with 10CFR50.73(a)(2)(i)(B) as a condition p~ohibjted by the plant's technical specifications. *
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Gerald B Slade General Manager CC Administra.tor, Region III, USNRC NRC Resident Inspector. - Palisades Attachment 9204200208 920413
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I I I On March 14, 1992, at approximately 1000 hour~, with the plant shutdown and refueling operations in progtess, it was .determined that containment integrity had been breached due the simultaneous opening of the secondary side handholes on the iteam generators and check valve.CK-0729 on the auxiliary feedwater line. All refueling operations were stopped and the mechanical maintenance supervisor was instructed to reassemble the check valve. An unmonitored*
release path to the environment*was not created and, therefore, there was no impact on the health and safety of the public.
The root cause of this event was personnel error for faiJure to identify the fact that certain plant configurations may result in a breach of* containment integrity.
Corrective action for this event includes: Reiterating to both the plant and contractor staff that work should not begin on work orders unless.they have
*been properly scheduled; Discussing pr~vention of this ev~nt with the plant and contractor schedulers; Reviewing plant periodic activity and control
( PPAC) work orders to determine whether certain pl ant configurations wil 1 result in a breach of containment integrity; and, Evaluating the need for a control system or process to identify plant configurations which may result in a breach of containment integrity.
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EVENT DESCRIPTION On March 14, 1992, at approximately 1060 ho~rs, with the plant shutdown and refueling operations in progress, it was determined that containment integrity
- had been breached due the simultaneous opening of the. secondary side handholes on the steam generators [SB] and check valve CK-0729 on the auxiliary feedwater line [BA;FCVJ. All refueling operations were stopped and the mechanical maintenance supervisor was instructed to reassemble_the check .
valve. All work orders currently released. for repair were reviewed.
- No other work orders, which had been released for repair, were found that could affect containment integrity. *The check valve was re-assembled by 1125 hours on March 14, 1992 .and refueling.operations were ~esumed at 1140 hours on March 14, .1992.
- This event is reportable to.the NRC in accordance with 10CFR50.73(a)(2)(i)(B).
as a ... condition prohibited by the plant's technical specifications. .
tAUSE OF THE EVENT.
The root cause of this event was the.result of a combination of lack of schedule control, ineffective communications, and p*ersonnel error.
1his event does not involve the failure of any e~uipment i~portant tci safety.
ANALYSIS OF THE EVENT The loss of containment integrity on March 14, 1992 was the result of a combination of lack of schedule control, ineffective communications, and personnel error. This conclusion is supported by the fact that (1) the. work.
aider for check valve CK-0729 was worked ahead -0f the*scheduled date without the mech~nical maintenance scheduler's knowledge and was, therefore, not sched~led,. (2) mechanical maintenance management and scheduling personnel did not effectively communicate to the valve contractor lead supervisors the limitations on work orders that were in the system window and, (3) the Shift Supervisor released the check valve work order for repair w1thout.taking into consideration that the steam: generator secondary side handhole flanges were removed. Each element is discussed in further detail below.
Note: A system window is a block of ti~~ within the outage schedule during which a particular system or component is made available for maintenance*and testing. Work orders on equipment within the defined system boundaries and within the dates and times the system window is open, may be sched~led and worked.
All valve ~ontractor and methanical maintenance wbrk orders are scheduled by the Mechanical Maintenance .Scheduler. In preparation for work a plant maintenance supervisor or valve contractor supervisor is ~iven work order packages to review. Additionally, depending upon system windows; the
- s~pervisor may obtain Workman's Protective Tagging prior to the opening of the system window. Prior to this event, it had been the practice of the ~alve
- contractor lead supervisor to look ahead in the schedule for opportunities to
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complete work before the scheduled d~te. If the valve ~ontractor lead supervisor had the work order package, Workman's Protective Tagging and Health Physics support, he would request the Shift Supervisor to release the work order package for repair and start the activity earlier in the system window.
The mechanical maintenance management endorsed th.is practice, as long as the valve contractor lead supervisor was working in accordance with approved plant procedures, Workman's Protective Tagging requirements, and within the system window.
- Operations Outage S~heduling personnel specifically discussed System Window 281, "Main Steam System" (inside Containment) with ~echanical mai~tenance
.man~gement and scheduling personnel~ Mechanical maintenance management and*
scheduling personnel were informed that withih System Window 281, only certain
_work orders could be worked when the steam generator secondary side handhole flanges were removed. This information was not effectively communicated to the. __yal ve contractor lead supervisors.
This event was reviewed with the Shift Supervisor who released the work order on check valve CK-0729 for r~pair. He. indicated that he released the work order based on the fact that the equipment had been properly tagged fdt
. workman protection and plant conditions were acceptable to permit the work.
He indicated that he did *not take into consideration that the steam generator secondary side hand hole flanges were removed for steam generator sludge lancing.
Another control mechanism that could have prevented this event and the could have been utilized in the work order is the section entitled "Effect on Plant tonditions."
- The information in th1s section is provided by the Shift Engineer if the work order is a plant periodic activity and control (PPAC) work order or, by the Operations Planner if th~ work order is not a PPAC work order. The section ~onveys information to the Shift Supervisor regarding the effect(s) on plant conditions when the equipment identified on the work order is released for repair. The PPAC work order for check valve CK~0729 did not contain the information that the disassembly of the check valve may result in the creation of an ~nmonitored release path from the containment when the secondary side of the steam generator was* open.
I Health Physics d~ta for the containment was reviewed for the period of time when the check valve and the steam generator secondary side handholes were open simultaneously. Health Physics air sample data for the containment was retrieved and reviewed. All of the samples showed iodine, particulate, or noble gas activities to be normal for refueling conditions. The Health Physics logbook was reviewed to determine if any unusual activities were recorded during the peri6d of time in question. Nothing unusual was noted in the logbook. *
- Since the check valve (CK-0729)*is located in the component cooling water room of the auxiliary building, a release of radioactivity from the path created by the open steam generator handholes and the check valve would have been contained within the auxiliary building HVAC system and monitored through the feedwater penetration room HVAC radiation monitor RIA 5710. Therefore~ an unmonitored release path to the environment was not created and there was ~o impact on the health and safety of the public.
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CORRECTIVE ACTION Corrective action for this event includes:
- 1. Reiterating to plant and contractor staff that work should not begiri on work orders unless they have been properly scheduled through the .
rilaintenance*scheduler or, the work order has been released by the.
- mechanical maintenance shift manager ..
- 2. Discussion of this event and ~ow it should be prevented was conducted with the valve contrattor contract coo~dinator, contractor supervision and*contr~ctor scheduler, as well as plant electri~al, instrument and control, and the Nuclear EDgineering and Construction (NECO) schedulers.
3~ Revi~wing PPACs for all SOER (INPO Significant Operating Experience Review) check valves that are directly connected to the secondary side of the steam generators and revise the "Effect on Plant Conditions" section to address whether releasing the equipment *will create an unmonitored release path from the containment.
- 4. Evaluating the need fot the Operation Department to develop a conttol system or process to identify that the secondary side of the steam
_ generator is open and, as a result, limitations on the release for
.repair of other equipment must be implemented.
ADDITIONAL INFORMATION Norie}}