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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML20024J3201994-10-0707 October 1994 LER 94-022-00:on 940907,TS Violation Occurred Due to Inadequate Fire Watch.Retrained Personnel Associated W/ Painting activities.W/941007 Ltr ML20029E2001994-05-13013 May 1994 LER 94-006-00:on 940414,SS Recognized That Required Frequency for Performing STP 057-3705 Had Been Exceeded. Caused by Inadequate Supervisory Methods.Corrective Action: Inhouse Tracking Process Will Be created.W/940513 Ltr ML20029C8741994-04-26026 April 1994 LER 93-026-01:on 931117,isolation of RCIC Sys Occurred Due to Apparent Failure of Relay.Three Relays Associated W/ Isolation Replaced & Shipped to Mfg for Failure Analysis.W/ 940426 Ltr ML20029C7021994-04-19019 April 1994 LER 90-003-05:on 900206,discovered Deficiencies in Thermo-Lag Fire Barrier Envelope Around Redundant Safe Shutdown.Firewatches Established in Areas Where Thermo Lag Used as barrier.W/940419 Ltr ML20046C3891993-08-0202 August 1993 LER 93-014-00:on 930701,installed Sprinkler Sys as Substitute for Passive fire-rated Barrier Due to Deficiency Identified in Fire Barrier Separation Requirements.Declared Fire Barriers Surrounding Valves degraded.W/930802 Ltr ML20046B8981993-07-29029 July 1993 LER 93-013-00:on 930629,high Pressure Core Spray Pump Failed to Start & Run During Surveillance Test Due to Failed Overfrequency Relay.Relay Tested & Installed in Switchgear. W/930729 Ltr ML20046A2361993-07-22022 July 1993 LER 93-008-01:on 930429,relief Request Improperly Prepared for Insvc Testing Program Results in Noncompliance W/Main Steam Isolation Valve Testing Requirement.Caused by Personnel Error.Testing Frequency Revised ML20045G6111993-07-0202 July 1993 LER 93-012-00:on 930603,deficiency in Plant Surveillance Test Procedures Identified.Caused by Primary Causal Factor Inattention to Detail During Initial Procedure Development Process.Surveillance Test Procedures performed.W/930702 Ltr ML20045D6991993-06-21021 June 1993 LER 93-011-00:on 930521,determined That Mode Switch Placed in Refuel Position During Testing of Switch Interlock Functions.Caused by Conflicting Info in Surveillance Procedures.Operating Procedure revised.W/930621 Ltr ML20045C0141993-06-14014 June 1993 LER 93-010-00:on 930514,SDC Lost for Approx Three Minutes When One SDC Suction Valve Closed Due to Initiation of Spurious ESF Actuation Signal.Caused by Personnel Error. Procedural Guidance revised.W/930614 Ltr ML20045C0021993-06-14014 June 1993 LER 93-003-01:on 930225,incidents Discovered Which Caused Interlock Mechanism in Upper Containment Airlocks at Elevation 171 to Operate Improperly.Case Study Training Class Developed for Airlock incidents.W/930614 Ltr ML20045A1461993-06-0404 June 1993 LER 93-009-00:on 930504,discovered That Surveillance Test Procedure for Control Bldg Chilled Water Sys Quarterly Pump Missed Due to Cognitive Personnel Error.Administrative Procedure Will Be revised.W/930604 Ltr ML20045A4261993-06-0101 June 1993 LER 93-002-02:on 930212,discovered That TS SRs Not Properly Implemented in Logic Sys Functional Tests Due to Inattention to Detail While Preparing Revs of Relevant Surveillance Test Procedures (Stp).Relevant STPs revised.W/930601 Ltr ML20044H3571993-06-0101 June 1993 LER 93-008-00:on 930429,investigation Determined That Relief Request for Inservice Testing of Pumps & Valves in Conflict W/Msiv Testing Requirements.Caused by Personnel Error.Relief Request 40 revised.W/930601 Ltr ML20044G7401993-05-26026 May 1993 LER 93-006-00:on 930419,MSIV Failed to Stroke Closed When Given Close Signal from CR Due to Poppet Sticking.Caused by Insufficient poppet-to-guide Rib Clearance.Stricter Controls Imposed to Control clearances.W/930526 Ltr ML20044F2541993-05-20020 May 1993 LER 93-007-00:on 930420,noted That an Isolation of Inboard & Outboard MSIV & Ms Line Drains Occurred.Caused by Lack of Personnel Knowledge of Unique Maint Conditions.Precaution Will Be Added to Sys Operating procedure.W/930520 Ltr ML20044D8511993-05-17017 May 1993 LER 93-005-00:on 930415,discovered That RCIC Steam Line Flow - High Timer Function Never Performed on Monthly Basis. Caused by Failure to Include Test in Initial Procedure Development Process.Procedures revised.W/930517 Ltr ML20024H2381991-05-21021 May 1991 LER 91-003-01:on 910322,Div II Control Power Circuit Deenergized,Resulting in Deenergization of Charcoal Filter Train Suction Dampers.Caused by Inadequate Work Plan.Plan Revised to Document Restoration of wiring.W/910521 Ltr ML20024G7441991-04-22022 April 1991 LER 91-003-00:on 910322,control Bldg Local Air Intake Radiation Monitor Control Power Circuit Deenergized, Resulting in Isolation of air-operated Dampers.Caused by Inadequate Work Plan.Work Plan revised.W/910422 Ltr ML20024G7181991-04-19019 April 1991 LER 91-004-00:on 910321,RCIC Turbine Main Steam Supply Line Outboard Containment Isolation Valve Isolated.Caused by Negative Trip Setpoint of Trip Unit Being Reached.Caution Added to RCIC Sys Operating procedures.W/910419 Ltr ML20029C1211991-03-14014 March 1991 LER 91-001-00:on 910212,use of Inadequate Control Room Filter Initiation Signal Due to Discrepancies Between Logic Diagrams.Main Control Room Doses Due to MSLB Outside Containment recalculated.W/910314 Ltr ML20029B1341991-02-26026 February 1991 LER 90-033-01:on 901104,RWCU Sys Isolation Occurred While Performing Plant Mod to Power Supply Wiring in Control Room Panel 1H13-P642.Caused by Removal of Terminal Screw.Power Supply reterminated.W/910226 Ltr ML20028H3961990-12-18018 December 1990 LER 90-032-01:on 901021,discovered That Five Snubbers Removed from Standby Svc Water Sys Piping in Violation of Tech Spec 3.7.4.Caused by Scheduling Error & Inadequate Review.Training Will Be Completed on 910331.W/901218 Ltr ML20024F7481990-12-10010 December 1990 LER 90-040-00:on 901110,technician Inadvertently Shorted Relay Terminals,Energizing Relay & Causing Emergency Diesel Generator to Start Unexpectedly.Caused by Personnel Error. Generator Manually secured.W/901210 Ltr ML20044B1951990-07-12012 July 1990 LER 90-003-01:on 900206 to 08,deficiencies Found in thermo-lag Fire Barrier Envelopes Redundant Safe Shutdown Circuits.Fire Watch Established.Util Working W/Vendor to Resolve discrepancies.W/900712 Ltr ML20044A3781990-06-22022 June 1990 LER 90-023-00:on 900523,discovered That Annulus Ventilation Radiation monitor,1RMS*RE11A Inoperable.Caused by Failure of Radiation Monitor Sample Pump & Failure of Switch to Actuate.Flow Switches replaced.W/900622 Ltr ML20043F4721990-06-0808 June 1990 LER 90-021-00:on 900509,RWCU Sys Differential Flow High Trip Instrumentation Inoperable for Period Greater than Allowed by Tech Spec.Caused by Misinterpretation of Tech Spec 3/4.3.2,Table 3.3.2.-1.4.Personnel retrained.W/900608 Ltr ML20043D5831990-06-0101 June 1990 LER 90-020-00:on 900504,radwaste Operator Entered High Radiation Area W/O Dose Rate Meter,Alarming Dosimeter or Radiation Protection Technician Coverage.Caused by Personnel Error.Training Provided to operators.W/900601 Ltr ML20043B8031990-05-24024 May 1990 LER 90-019-00:on 900425,RWCU Sys Isolation & ESF Actuation Occurred After Completion of Channel Check of Riley Temp Trip Unit.Caused by Unit Exceeding Differential Temp Setpoint of 46 F.Unit replaced.W/900524 Ltr ML20043B3301990-05-21021 May 1990 LER 90-017-00:on 900419,inadequate Fire Barrier in Shake Space Occurred Contrary to Tech Spec.Caused by Oversight. Roving Fire Watch Scheduled.Maint Will Rework Voids & Install Seismic Gap seal.W/900521 Ltr ML20043C0281990-05-19019 May 1990 LER 90-018-00:on 900420,ESF Actuation Occurred Causing Reactor Water Sample Containment Isolation Valve to Close. Caused by Failure of Fuse Which Deenergized Isolation Logic of Valves.Fuse replaced.W/900518 Ltr ML20042G7981990-05-10010 May 1990 LER 90-016-00:on 900414,insulator Fault on Local Grid Resulted in Trip of 500 Kv Breaker.Caused by Spurious Alarm Signal from Control Room Local Intake Radiation Monitor 1RMS*RE13B.Sys Returned to Normal operation.W/900510 Ltr ML20042G8001990-05-0909 May 1990 LER 90-015-00:on 900409,loss of Div II Reactor Protection Sys Bus Occurred Due to Trip of Electrical Protection Assembly.Another Trip Also Occurred on 900415.Caused by Faulty Integrated Circuit logics.W/900509 Ltr ML20042G4501990-05-0707 May 1990 LER 90-013-00:on 900405,discovered That Control Bldg Chiller Motor Current Limiter C Set Incorrectly at 56% Instead of 100%.Caused by Incorrect Setting & Maint Activities.Loop Calibr Data Sheet revised.W/900507 Ltr ML20042G4531990-05-0707 May 1990 LER 90-014-00:on 900407,reactor Scram Occurred While Testing Main Turbine Combined Intermediate Valves.Caused by Low Pressure Signal from Emergency Trip Sys of Electrohydraulic Control Sys.Two Solenoid Valves replaced.W/900507 Ltr ML20042F4731990-05-0101 May 1990 LER 90-012-00:on 900401,ESF Actuations Occurred Due to Electrical Protection Assembly Breakers Trip.Caused by Voltage Regulator Failure.Replacement Voltage Regulator Card Installed in MG 1C71-S001B.W/900501 Ltr ML20042E2231990-04-0909 April 1990 LER 90-007-00:on 900311,control Bldg Ventilation Sys Isolated & Filtration Unit Initiated.Caused by Severe Electrical Transient.Performance of Radiation Monitors Improved Prior to Implementation of procedures.W/900409 Ltr ML20012C0741990-03-12012 March 1990 LER 90-004-00:on 900211,Div II Emergency 125-volt Dc Bus Experienced Voltage Spike,Causing Topaz Inverter to Trip & Resulting in Loss of Power to Control Room Panel.Cause Unknown.Setpoint Changes Being evaluated.W/900312 Ltr ML20012C4191990-03-0808 March 1990 LER 90-003-00:on 900206,found That Several Minor Deficiencies Existed in thermo-lag Fire Barrier Envelopes Redundant Safe Shutdown Circuits.Util Currently Working W/ Vendor to Resolve Identified discrepancies.W/900308 Ltr ML20011E2491990-01-31031 January 1990 LER 88-018-04:on 880825,reactor Scram Occurred Due to Main Generator Exciter Brush Failure.Preventive Maint Procedure Revised to Establish Specific Wear Criteria at Which Brushes to Be replaced.W/900131 Ltr ML20011E2461990-01-31031 January 1990 LER 89-036-01:on 891007,discovered That Various motor- Operated Valves Energized,Contrary to Assumptions Contained in Plant Fire Hazards Analysis.Cause Not Stated.Operations Initiated Required Fire Watches on valves.W/900131 Ltr ML20011E1191990-01-30030 January 1990 LER 90-001-00:on 900103,isolation of RCIC Steam Supply Inboard Isolation Valve Occurred During Surveillance Testing of RCIC Sys.Caused by Technician Lifting Wrong Lead,Causing ESF Actuation.Lead Relanded on terminal.W/900130 Ltr ML20011E1181990-01-30030 January 1990 LER 89-033-01:on 890916,loss of Power to Div II 120-volt Ac Distribution Panel Caused auto-start of Standby Gas Treatment & Annulus Mixing Sys,Resulting in ESF Actuations. Caused by Transformer Failure.Valves opened.W/900130 Ltr ML20005G1641990-01-10010 January 1990 LER 89-044-00:on 891211,unplanned ESF Actuation Occurred, Resulting in Isolation of Rcic.Caused by Technician Failing to Perform Steps of Surveillance Test Procedure in Sequence.Div II Isolation Signal reset.W/900110 Ltr ML20005G1661990-01-10010 January 1990 LER 89-045-00:on 891212,Div I Standby Svc Water Pumps Received Automatic Start Signal Due to Spurious Low Svc Water Pressure Signal When Normal Svc Water Pump Secured. Signal Cleared & Sys Restored to Normal lineup.W/900110 Ltr ML20005E8521990-01-0202 January 1990 LER 89-043-00:on 891201.two Outboard MSIVs Inoperable Due to Failure of Corresponding Fast Closure solenoid-operated Valve.Caused by Incomplete Removal of Silicone Lubricant. Lubricant Removed by Application of Acetone.W/900102 Ltr ML20005E8511990-01-0202 January 1990 LER 89-042-01:on 891201,main Turbine Generator Tripped, Resulting in Reactor Scram.Caused by Sensing Fault on Offsite 230 Kv Line.Sys Maint Procedure Being Revised to Include Test of Failed Portion of relay.W/900102 Ltr ML20005E1381989-12-26026 December 1989 LER 89-041-00:on 891125,unplanned ESF Actuation Occurred as Result of Two Leads Shorted Together During Testing of Control Circuitry,Causing Valve Isolation from Suppression Pool.Sys Lineup Restored to Normal position.W/891226 Ltr ML20011D6201989-12-18018 December 1989 LER 89-040-00:on 891117,surveillance Test of Div II Penetration Valve Leakage Control Sys Air Supply Header Pressure Not Performed within Allowable Tolerance.Addl Training of Scheduling Group Will Be provided.W/891218 Ltr ML20011D1371989-12-14014 December 1989 LER 89-039-00:on 891114,discovered That Required post-maint Overall Leak Rate Test on Upper Containment Airlock Not Performed After Replacement of Inflatable Seal.Caused by Personnel Error.Maint Procedure revised.W/891214 Ltr 1994-05-13
[Table view] Category:RO)
MONTHYEARML20024J3201994-10-0707 October 1994 LER 94-022-00:on 940907,TS Violation Occurred Due to Inadequate Fire Watch.Retrained Personnel Associated W/ Painting activities.W/941007 Ltr ML20029E2001994-05-13013 May 1994 LER 94-006-00:on 940414,SS Recognized That Required Frequency for Performing STP 057-3705 Had Been Exceeded. Caused by Inadequate Supervisory Methods.Corrective Action: Inhouse Tracking Process Will Be created.W/940513 Ltr ML20029C8741994-04-26026 April 1994 LER 93-026-01:on 931117,isolation of RCIC Sys Occurred Due to Apparent Failure of Relay.Three Relays Associated W/ Isolation Replaced & Shipped to Mfg for Failure Analysis.W/ 940426 Ltr ML20029C7021994-04-19019 April 1994 LER 90-003-05:on 900206,discovered Deficiencies in Thermo-Lag Fire Barrier Envelope Around Redundant Safe Shutdown.Firewatches Established in Areas Where Thermo Lag Used as barrier.W/940419 Ltr ML20046C3891993-08-0202 August 1993 LER 93-014-00:on 930701,installed Sprinkler Sys as Substitute for Passive fire-rated Barrier Due to Deficiency Identified in Fire Barrier Separation Requirements.Declared Fire Barriers Surrounding Valves degraded.W/930802 Ltr ML20046B8981993-07-29029 July 1993 LER 93-013-00:on 930629,high Pressure Core Spray Pump Failed to Start & Run During Surveillance Test Due to Failed Overfrequency Relay.Relay Tested & Installed in Switchgear. W/930729 Ltr ML20046A2361993-07-22022 July 1993 LER 93-008-01:on 930429,relief Request Improperly Prepared for Insvc Testing Program Results in Noncompliance W/Main Steam Isolation Valve Testing Requirement.Caused by Personnel Error.Testing Frequency Revised ML20045G6111993-07-0202 July 1993 LER 93-012-00:on 930603,deficiency in Plant Surveillance Test Procedures Identified.Caused by Primary Causal Factor Inattention to Detail During Initial Procedure Development Process.Surveillance Test Procedures performed.W/930702 Ltr ML20045D6991993-06-21021 June 1993 LER 93-011-00:on 930521,determined That Mode Switch Placed in Refuel Position During Testing of Switch Interlock Functions.Caused by Conflicting Info in Surveillance Procedures.Operating Procedure revised.W/930621 Ltr ML20045C0141993-06-14014 June 1993 LER 93-010-00:on 930514,SDC Lost for Approx Three Minutes When One SDC Suction Valve Closed Due to Initiation of Spurious ESF Actuation Signal.Caused by Personnel Error. Procedural Guidance revised.W/930614 Ltr ML20045C0021993-06-14014 June 1993 LER 93-003-01:on 930225,incidents Discovered Which Caused Interlock Mechanism in Upper Containment Airlocks at Elevation 171 to Operate Improperly.Case Study Training Class Developed for Airlock incidents.W/930614 Ltr ML20045A1461993-06-0404 June 1993 LER 93-009-00:on 930504,discovered That Surveillance Test Procedure for Control Bldg Chilled Water Sys Quarterly Pump Missed Due to Cognitive Personnel Error.Administrative Procedure Will Be revised.W/930604 Ltr ML20045A4261993-06-0101 June 1993 LER 93-002-02:on 930212,discovered That TS SRs Not Properly Implemented in Logic Sys Functional Tests Due to Inattention to Detail While Preparing Revs of Relevant Surveillance Test Procedures (Stp).Relevant STPs revised.W/930601 Ltr ML20044H3571993-06-0101 June 1993 LER 93-008-00:on 930429,investigation Determined That Relief Request for Inservice Testing of Pumps & Valves in Conflict W/Msiv Testing Requirements.Caused by Personnel Error.Relief Request 40 revised.W/930601 Ltr ML20044G7401993-05-26026 May 1993 LER 93-006-00:on 930419,MSIV Failed to Stroke Closed When Given Close Signal from CR Due to Poppet Sticking.Caused by Insufficient poppet-to-guide Rib Clearance.Stricter Controls Imposed to Control clearances.W/930526 Ltr ML20044F2541993-05-20020 May 1993 LER 93-007-00:on 930420,noted That an Isolation of Inboard & Outboard MSIV & Ms Line Drains Occurred.Caused by Lack of Personnel Knowledge of Unique Maint Conditions.Precaution Will Be Added to Sys Operating procedure.W/930520 Ltr ML20044D8511993-05-17017 May 1993 LER 93-005-00:on 930415,discovered That RCIC Steam Line Flow - High Timer Function Never Performed on Monthly Basis. Caused by Failure to Include Test in Initial Procedure Development Process.Procedures revised.W/930517 Ltr ML20024H2381991-05-21021 May 1991 LER 91-003-01:on 910322,Div II Control Power Circuit Deenergized,Resulting in Deenergization of Charcoal Filter Train Suction Dampers.Caused by Inadequate Work Plan.Plan Revised to Document Restoration of wiring.W/910521 Ltr ML20024G7441991-04-22022 April 1991 LER 91-003-00:on 910322,control Bldg Local Air Intake Radiation Monitor Control Power Circuit Deenergized, Resulting in Isolation of air-operated Dampers.Caused by Inadequate Work Plan.Work Plan revised.W/910422 Ltr ML20024G7181991-04-19019 April 1991 LER 91-004-00:on 910321,RCIC Turbine Main Steam Supply Line Outboard Containment Isolation Valve Isolated.Caused by Negative Trip Setpoint of Trip Unit Being Reached.Caution Added to RCIC Sys Operating procedures.W/910419 Ltr ML20029C1211991-03-14014 March 1991 LER 91-001-00:on 910212,use of Inadequate Control Room Filter Initiation Signal Due to Discrepancies Between Logic Diagrams.Main Control Room Doses Due to MSLB Outside Containment recalculated.W/910314 Ltr ML20029B1341991-02-26026 February 1991 LER 90-033-01:on 901104,RWCU Sys Isolation Occurred While Performing Plant Mod to Power Supply Wiring in Control Room Panel 1H13-P642.Caused by Removal of Terminal Screw.Power Supply reterminated.W/910226 Ltr ML20028H3961990-12-18018 December 1990 LER 90-032-01:on 901021,discovered That Five Snubbers Removed from Standby Svc Water Sys Piping in Violation of Tech Spec 3.7.4.Caused by Scheduling Error & Inadequate Review.Training Will Be Completed on 910331.W/901218 Ltr ML20024F7481990-12-10010 December 1990 LER 90-040-00:on 901110,technician Inadvertently Shorted Relay Terminals,Energizing Relay & Causing Emergency Diesel Generator to Start Unexpectedly.Caused by Personnel Error. Generator Manually secured.W/901210 Ltr ML20044B1951990-07-12012 July 1990 LER 90-003-01:on 900206 to 08,deficiencies Found in thermo-lag Fire Barrier Envelopes Redundant Safe Shutdown Circuits.Fire Watch Established.Util Working W/Vendor to Resolve discrepancies.W/900712 Ltr ML20044A3781990-06-22022 June 1990 LER 90-023-00:on 900523,discovered That Annulus Ventilation Radiation monitor,1RMS*RE11A Inoperable.Caused by Failure of Radiation Monitor Sample Pump & Failure of Switch to Actuate.Flow Switches replaced.W/900622 Ltr ML20043F4721990-06-0808 June 1990 LER 90-021-00:on 900509,RWCU Sys Differential Flow High Trip Instrumentation Inoperable for Period Greater than Allowed by Tech Spec.Caused by Misinterpretation of Tech Spec 3/4.3.2,Table 3.3.2.-1.4.Personnel retrained.W/900608 Ltr ML20043D5831990-06-0101 June 1990 LER 90-020-00:on 900504,radwaste Operator Entered High Radiation Area W/O Dose Rate Meter,Alarming Dosimeter or Radiation Protection Technician Coverage.Caused by Personnel Error.Training Provided to operators.W/900601 Ltr ML20043B8031990-05-24024 May 1990 LER 90-019-00:on 900425,RWCU Sys Isolation & ESF Actuation Occurred After Completion of Channel Check of Riley Temp Trip Unit.Caused by Unit Exceeding Differential Temp Setpoint of 46 F.Unit replaced.W/900524 Ltr ML20043B3301990-05-21021 May 1990 LER 90-017-00:on 900419,inadequate Fire Barrier in Shake Space Occurred Contrary to Tech Spec.Caused by Oversight. Roving Fire Watch Scheduled.Maint Will Rework Voids & Install Seismic Gap seal.W/900521 Ltr ML20043C0281990-05-19019 May 1990 LER 90-018-00:on 900420,ESF Actuation Occurred Causing Reactor Water Sample Containment Isolation Valve to Close. Caused by Failure of Fuse Which Deenergized Isolation Logic of Valves.Fuse replaced.W/900518 Ltr ML20042G7981990-05-10010 May 1990 LER 90-016-00:on 900414,insulator Fault on Local Grid Resulted in Trip of 500 Kv Breaker.Caused by Spurious Alarm Signal from Control Room Local Intake Radiation Monitor 1RMS*RE13B.Sys Returned to Normal operation.W/900510 Ltr ML20042G8001990-05-0909 May 1990 LER 90-015-00:on 900409,loss of Div II Reactor Protection Sys Bus Occurred Due to Trip of Electrical Protection Assembly.Another Trip Also Occurred on 900415.Caused by Faulty Integrated Circuit logics.W/900509 Ltr ML20042G4501990-05-0707 May 1990 LER 90-013-00:on 900405,discovered That Control Bldg Chiller Motor Current Limiter C Set Incorrectly at 56% Instead of 100%.Caused by Incorrect Setting & Maint Activities.Loop Calibr Data Sheet revised.W/900507 Ltr ML20042G4531990-05-0707 May 1990 LER 90-014-00:on 900407,reactor Scram Occurred While Testing Main Turbine Combined Intermediate Valves.Caused by Low Pressure Signal from Emergency Trip Sys of Electrohydraulic Control Sys.Two Solenoid Valves replaced.W/900507 Ltr ML20042F4731990-05-0101 May 1990 LER 90-012-00:on 900401,ESF Actuations Occurred Due to Electrical Protection Assembly Breakers Trip.Caused by Voltage Regulator Failure.Replacement Voltage Regulator Card Installed in MG 1C71-S001B.W/900501 Ltr ML20042E2231990-04-0909 April 1990 LER 90-007-00:on 900311,control Bldg Ventilation Sys Isolated & Filtration Unit Initiated.Caused by Severe Electrical Transient.Performance of Radiation Monitors Improved Prior to Implementation of procedures.W/900409 Ltr ML20012C0741990-03-12012 March 1990 LER 90-004-00:on 900211,Div II Emergency 125-volt Dc Bus Experienced Voltage Spike,Causing Topaz Inverter to Trip & Resulting in Loss of Power to Control Room Panel.Cause Unknown.Setpoint Changes Being evaluated.W/900312 Ltr ML20012C4191990-03-0808 March 1990 LER 90-003-00:on 900206,found That Several Minor Deficiencies Existed in thermo-lag Fire Barrier Envelopes Redundant Safe Shutdown Circuits.Util Currently Working W/ Vendor to Resolve Identified discrepancies.W/900308 Ltr ML20011E2491990-01-31031 January 1990 LER 88-018-04:on 880825,reactor Scram Occurred Due to Main Generator Exciter Brush Failure.Preventive Maint Procedure Revised to Establish Specific Wear Criteria at Which Brushes to Be replaced.W/900131 Ltr ML20011E2461990-01-31031 January 1990 LER 89-036-01:on 891007,discovered That Various motor- Operated Valves Energized,Contrary to Assumptions Contained in Plant Fire Hazards Analysis.Cause Not Stated.Operations Initiated Required Fire Watches on valves.W/900131 Ltr ML20011E1191990-01-30030 January 1990 LER 90-001-00:on 900103,isolation of RCIC Steam Supply Inboard Isolation Valve Occurred During Surveillance Testing of RCIC Sys.Caused by Technician Lifting Wrong Lead,Causing ESF Actuation.Lead Relanded on terminal.W/900130 Ltr ML20011E1181990-01-30030 January 1990 LER 89-033-01:on 890916,loss of Power to Div II 120-volt Ac Distribution Panel Caused auto-start of Standby Gas Treatment & Annulus Mixing Sys,Resulting in ESF Actuations. Caused by Transformer Failure.Valves opened.W/900130 Ltr ML20005G1641990-01-10010 January 1990 LER 89-044-00:on 891211,unplanned ESF Actuation Occurred, Resulting in Isolation of Rcic.Caused by Technician Failing to Perform Steps of Surveillance Test Procedure in Sequence.Div II Isolation Signal reset.W/900110 Ltr ML20005G1661990-01-10010 January 1990 LER 89-045-00:on 891212,Div I Standby Svc Water Pumps Received Automatic Start Signal Due to Spurious Low Svc Water Pressure Signal When Normal Svc Water Pump Secured. Signal Cleared & Sys Restored to Normal lineup.W/900110 Ltr ML20005E8521990-01-0202 January 1990 LER 89-043-00:on 891201.two Outboard MSIVs Inoperable Due to Failure of Corresponding Fast Closure solenoid-operated Valve.Caused by Incomplete Removal of Silicone Lubricant. Lubricant Removed by Application of Acetone.W/900102 Ltr ML20005E8511990-01-0202 January 1990 LER 89-042-01:on 891201,main Turbine Generator Tripped, Resulting in Reactor Scram.Caused by Sensing Fault on Offsite 230 Kv Line.Sys Maint Procedure Being Revised to Include Test of Failed Portion of relay.W/900102 Ltr ML20005E1381989-12-26026 December 1989 LER 89-041-00:on 891125,unplanned ESF Actuation Occurred as Result of Two Leads Shorted Together During Testing of Control Circuitry,Causing Valve Isolation from Suppression Pool.Sys Lineup Restored to Normal position.W/891226 Ltr ML20011D6201989-12-18018 December 1989 LER 89-040-00:on 891117,surveillance Test of Div II Penetration Valve Leakage Control Sys Air Supply Header Pressure Not Performed within Allowable Tolerance.Addl Training of Scheduling Group Will Be provided.W/891218 Ltr ML20011D1371989-12-14014 December 1989 LER 89-039-00:on 891114,discovered That Required post-maint Overall Leak Rate Test on Upper Containment Airlock Not Performed After Replacement of Inflatable Seal.Caused by Personnel Error.Maint Procedure revised.W/891214 Ltr 1994-05-13
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARRBG-45144, Monthly Operating Rept for Sept 1999 for River Bend Station. with1999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for River Bend Station. with ML20216G1201999-09-0909 September 1999 Rev 3 to Rbs,Cycle 9 Colr RBG-45110, Monthly Operating Rept for Aug 1999 for River Bend Station, Unit 1.With1999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for River Bend Station, Unit 1.With RBG-45087, Special Rept:On 990510,LPCI a & LPCS Injected Into Rv for Less than Two Minutes.Caused by Electrical Transient in One of ECCS Power Supplies.Operators Verified Reactor Cavity Level & Closed Injection Valves to Stop Injection1999-08-0606 August 1999 Special Rept:On 990510,LPCI a & LPCS Injected Into Rv for Less than Two Minutes.Caused by Electrical Transient in One of ECCS Power Supplies.Operators Verified Reactor Cavity Level & Closed Injection Valves to Stop Injection ML20210K4721999-08-0303 August 1999 SER Accepting Licensee 180-day Response to GL 95-07, Pressure Locking & Thermal Binding of Safety-Related Power-Operated Gate Valves RBG-45091, Monthly Operating Rept for July 1999 for River Bend Station, Unit 1.With1999-07-31031 July 1999 Monthly Operating Rept for July 1999 for River Bend Station, Unit 1.With ML20210C6391999-07-0202 July 1999 Rev 2 to River Bend Station,Cycle 9 Colr RBG-45055, Monthly Operating Rept for June 1999 for River Bend Station, Unit 1.With1999-06-30030 June 1999 Monthly Operating Rept for June 1999 for River Bend Station, Unit 1.With ML20196J8031999-06-24024 June 1999 Rev 1 to Rbs,Cycle 9 Colr RBG-45028, Monthly Operating Rept for May 1999 for River Bend Station, Unit 1.With1999-05-31031 May 1999 Monthly Operating Rept for May 1999 for River Bend Station, Unit 1.With RBG-45016, Monthly Operating Rept for Apr 1999 for River Bend Station, Unit 1.With1999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for River Bend Station, Unit 1.With ML20206A2111999-04-21021 April 1999 Safety Evaluation Authorizing Pump Relief Request PRR-001 & Valve Relief Request VRR-001 & Denying Valve Relief Request VRR-002 RBG-44969, Monthly Operating Rept for Mar 1999 for River Bend Station, Unit 1.With1999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for River Bend Station, Unit 1.With ML20205S0601999-03-31031 March 1999 Rept on Status of Public Petitions Under 10CFR2.206 with Status Change from Previous Update,990331 ML20205D5481999-03-26026 March 1999 SER Accepting Util Proposed Alternative to Exam Weld AA with Weld Volume Coverage of 62 Percent for First 10-year Insp Interval Pursuant to 10CFR50.55a(a)(3)(ii) & 10CFR50.55a(g)(6)(ii)(A)(5) RBG-44930, Monthly Operating Rept for Feb 1999 for River Bend Station, Unit 1.With1999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for River Bend Station, Unit 1.With RBG-44826, Monthly Operating Rept for Dec 1998 for River Bend Station Unit 1.With1998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for River Bend Station Unit 1.With ML20198K2701998-12-22022 December 1998 Rev 1 to RBS Cycle 8 Colr RBG-44773, Monthly Operating Rept for Nov 1998 for River Bend Station, Unit 1.With1998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for River Bend Station, Unit 1.With RBG-44727, LER 98-S01-00:on 981021,identified That Contract Employee with Temporary Access Authorization Failed to Disclose Complete Criminal & Employment History.Individual Denied Access to Plants for Five Years.With1998-11-17017 November 1998 LER 98-S01-00:on 981021,identified That Contract Employee with Temporary Access Authorization Failed to Disclose Complete Criminal & Employment History.Individual Denied Access to Plants for Five Years.With ML20195C4841998-11-0606 November 1998 SER Accepting QA Program Change to Consolidate Four Existing QA Programs for Arkansas Nuclear One,Grand Gulf Nuclear Station,River Bend Station & Waterford 3 Steam Electric Station Into Single QA Program ML20155H3491998-11-0303 November 1998 Safety Evaluation Granting Requests for Relief RR2-0001, RR2-0002 & RR2-0003 RBG-44719, Monthly Operating Rept for Oct 1998 for River Bend Station, Unit 1.With1998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for River Bend Station, Unit 1.With ML20155C1351998-10-26026 October 1998 Rev B to Entergy QA Program Manual RBG-44677, Monthly Operating Rept for Sept 1998 for River Bend Station, Unit 1.With1998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for River Bend Station, Unit 1.With ML20154E2171998-09-28028 September 1998 Follow-up Part 21 Rept Re Defect with 1200AC & 1200BC Recorders Built Under Westronics 10CFR50 App B Program. Westronics Has Notified Bvps,Ano & RBS & Is Currently Making Arrangements to Implement Design Mods ML20151S5421998-09-0303 September 1998 Safety Evaluation Opposing Licensee Thermal Model as Currently Implemented.Evaluation Recommended to Be Used in Any follow-up Site Insp RBG-44629, Monthly Operating Rept for Aug 1998 for River Bend Station, Unit 1.With1998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for River Bend Station, Unit 1.With ML20236X2351998-08-0505 August 1998 Part 21 Rept Re Defect Associated W/Westronics 1200AC & 1200BC Recorders Built Under Westronics 10CFR50,App B Program.Beaver Valley,Arkansas Nuclear One & River Bend Station Notified.Design Mod Is Being Developed RBG-44600, Monthly Operating Rept for July 1998 for River Bend Station1998-07-31031 July 1998 Monthly Operating Rept for July 1998 for River Bend Station RBG-44564, Monthly Operating Rept for June 1998 for River Bend Station, Unit 11998-06-30030 June 1998 Monthly Operating Rept for June 1998 for River Bend Station, Unit 1 ML20249A6431998-06-12012 June 1998 SER Accepting 980427 Request for Change to River Bend QA Manual Program Description,Per 10CFR50.54(a)(3) RBG-44539, Monthly Operating Rept for May 1998 for River Bend Station, Unit 11998-05-31031 May 1998 Monthly Operating Rept for May 1998 for River Bend Station, Unit 1 RBG-44501, Monthly Operating Rept for Apr 1998 for River Bend Station, Unit 11998-04-30030 April 1998 Monthly Operating Rept for Apr 1998 for River Bend Station, Unit 1 ML20217M8951998-04-30030 April 1998 QA Program Manual ML20217P8281998-04-0707 April 1998 Safety Evaluation Accepting Relief Authorization for Alternative to Requirements of ASME Section Xi,Subarticle IWA-5250 Bolting Exam for Plants,Per 10CFR50.55a(a)(3)(i) RBG-44458, Monthly Operating Rept for Mar 1998 for River Bend Station, Unit 11998-03-31031 March 1998 Monthly Operating Rept for Mar 1998 for River Bend Station, Unit 1 RBG-44423, Monthly Operating Rept for Feb 1998 for River Bend Station Unit 11998-02-28028 February 1998 Monthly Operating Rept for Feb 1998 for River Bend Station Unit 1 ML20203L6631998-02-11011 February 1998 Rev 0 to River Bend Station,1998 Emergency Preparedness Exercise RBG-44385, Monthly Operating Rept for Jan 1998 for River Bend Station, Unit 11998-01-31031 January 1998 Monthly Operating Rept for Jan 1998 for River Bend Station, Unit 1 RBG-44353, Monthly Operating Rept for Dec 1997 for River Bend Station, Unit 11997-12-31031 December 1997 Monthly Operating Rept for Dec 1997 for River Bend Station, Unit 1 RBG-44460, Forwards Annual Radiological Environmental Operating Rept, for Period Jan-Dec 19971997-12-31031 December 1997 Forwards Annual Radiological Environmental Operating Rept, for Period Jan-Dec 1997 ML20203H9891997-12-12012 December 1997 Part 21 Rept Re Potential Manufacturing Defect of Enterprise DSR-4 & DSRV-4 Edgs.Cooper Energy Svcs Supplied 1A-7840 Adjusting Screw to Affected Utils & Sites.River Bend Station Replaced W/Acceptable Assemblies ML20202E9941997-12-0101 December 1997 ISI Plan Second Ten-Yr Interval (Dec 1,1997-Nov 30,2007) ML20199K9741997-11-30030 November 1997 Brief Aerial Photography Analysis of RBS at St Francisville,LA:1996-1997 RBG-44337, Monthly Operating Rept for Nov 1997 for River Bend Station, Unit 11997-11-30030 November 1997 Monthly Operating Rept for Nov 1997 for River Bend Station, Unit 1 ML20202F0191997-11-28028 November 1997 Safety Evaluation Approving Transfer of License NPF-47 for River Bend Station,Unit 1 ML20199H3711997-11-19019 November 1997 SER Accepting Approving Request Relief from Requirements of Section XI, Rule for Inservice Insp of NPP Components, of ASME for Current or New 10-year Inservice Insp Interval IAW 50.55(a)(3)(i) of 10CFR50 RBG-44295, Monthly Operating Rept for Oct 1997 for River Bend Station Unit 11997-10-31031 October 1997 Monthly Operating Rept for Oct 1997 for River Bend Station Unit 1 RBG-44243, LER 97-S03-00:on 970911,contract Employee Was Granted Temporary Access After Failing to List Prior Employment Termination & Access Denial.Caused by Employee Failure to Provide Accurate Info.Updated Info Re Employee1997-10-13013 October 1997 LER 97-S03-00:on 970911,contract Employee Was Granted Temporary Access After Failing to List Prior Employment Termination & Access Denial.Caused by Employee Failure to Provide Accurate Info.Updated Info Re Employee 1999-09-09
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GULF STATES UTILITIES COMPANY fWF lt (1[ND ST A7LON PO*iT Of Fif.E BOX 720 $1 Fli ANCISVkLL. LOUILAN A 70775
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June 14,'1993 RBG-38626 File Nos. G9.5, G9.25.1.3 U.S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555 Gentlemen:
River Bend Station - Unit 1 Docket No. 50-458 Please find enclosed Licensee Event Repon No.93-010 for R.iver Bend Station -
Unit 1. This report is submitted pursuant to 10CFR50.73.
Sincerely, 6 ) a) n ~ s
. E. Booker Manager - Safety Assessment and Quality Verification
, River Bend Nuclear Group N 'SDPP JPS/FRC/DC Jt[H/VCC/kym 180i;aD I
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cc: U.S. Nuclear Regulatory Commission 611 Ryan Plaza Drive, Suite 400 Arlington, TX 76011 NRC Resident Inspector P.O. Box 1051 St. Francisville, LA 70775 INPO Records Center 700 Galleria Parkway Atlanta, GA 30339-5957 Mr. C.R. Oberg Public Utility Commission of Texas 7800 Shoal Creek Blvd., Suite 400 Nonh Austin, TX 78757 Depanment of Environmental Quality Radiation Protection Division P.O. Box 82135 Baton Rouge, LA 70884-2135 ATrN: Administrator i
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NRC FORM 366 ~
U.S. NUCLEAR REGULATORY COMMISSION [ APPROVED FY oMB NO. 3150-0104
- s % EXPIRES 5/31/95 ESTIMATED BunDEN PER AFLPONOC TO COMPLY W7TH THS INF 3RMA TKW COLLECTION NEQUE ST: 50.0 HRS. FORWARD LICENSEE EVENT REPORT (LER) ccMMum ewoNG sVRotN esT,vATe TO THE ,NronMATiON AND RE COHDS MA?.AGCM[ NT BRANCH (MNB9 7714), U.S NUCLEAR Hr GULATOHY COVMGSON. Af4H)NG7DN. DC 20S550301 AND TO THE PAPERWORM Rf DUCTION PROJECT (31 %o t 04). OrFICE OF (See reverse for required number of digits / characters for each block) MANAGEMENT AND BUDGLT WASH:NGTON, DC 20S03 ACILITV NAME p) DOCKET NUMBLR (2) PAGE (3)
[_ RIVER BEND STATION 05000 458 10F 4 T"'E (*) LOSS OF SIlUTDOWN COOLING DURING DE-ENERGIZATIOl OF A POWER DISTRIBUTION PANEL
- EVENT DATE (5) LER NUMBER (6 REPORT NUMBER (7) OTHER FACILITIES INVOLVED (8) sEourN w nEWON f ACUM NAML DUC C NUMBLR MoNm na vrAq YEAR MONTH DAY YEAR 05000 FALiuTY NAMia DCKXET NUMBER 05 14 03 93 - 010 -
00 OG 14 93 05000 OPERATING _TjHIS REPORT IS SUDMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR 1: (Check one or more) (11)
MODE (9) 20.402(b) 20 405(c) x 50.73(a)(2)(iv) 73.71(b) ,
POWER 20 405:aH1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73,71 (c)
LEVEL (10) 0 20 405(a)(1)(n) 50 36(c)(2) 50.73(a)(2)(vit) ol HER I 20 405(a)(1)(m) 50.73(a)(2)(i) 50.73(a)(2)(vm)(A) 'W "' A*ad be'ow and m Text, NRC l 20 405(a)(1)Dvl 50.73(a)(2)(H) 50.73(a)(2)(vm)(B) rm w,A; 20 405(a)(11(v) 50 73(a)(2)(m) 50.73(a)(2)(x)
LICENSEE CONTACT FOR THIS LER (12) e,tsu na enoNE Nuvatn unovae A es cow D.N. Lorfing- Supervisor, Nuclear Licensing (504) 381-4157
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COMPLETE ONE LINE FoR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13) cAur_r su w roMPoNrNT WNUF ACTURER CAULE SYSTEV COMP NE.NT M ANUF ACTURE R f D
SUPPLEMENTAL REPORT EXPECTED (14) EXPECTED WH W iLA4 vrs SUBMISSION p p... wew t a rcan wayssnN DATn
,, 08 14 93 DATE (15)
ABSTRACT (Lrmat to 1400 spaces, i e., approximately 15 singie-spaced typewntten lines) (16) i On 05/lF93 with the p!:nt in Oper:Sn 1 Condition 4 (Cold Shutdcwn), shuidown cooling (SDC) was lost for approximately three minutes when one of the SDC suction valves closed. This occurred due to the initiation of a spurious engineered safety feature (ESP) actuation signal during de-energization of a 120 VAC power distribution panel. Therefore, this report is submitted pursuant to 10CFR50.73(b)(2)(iv) as an ESF actuation. ;
The root cause of this incident was that on-shift management personnel missed the need for compensatory measures when opening breaker #22 to prevent a loss of SDC. Corrective actions include revising procedural guidance to clarify which valve isolates when breaker #22 is opened.
The dumtion of the loss was minimal (3 minutes) and instrumentation indicated no change in reactor coolant temperature.
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REQUIRED NUMBER OF DIGITS / CHARACTERS FOR EACH BLOCK -
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1 UP TO 46 FACILITY NAME i
2 DOCKET NUMBER 'l 3 IN ADDITION TO 05000 3 VARIES PAGE NUMBER .
4 UP TO 76 TULE 5 EVENT DATE 2 PER BLOCK 7 TOTAL F LER NUMBER 3 FOR SEQUENTIAL NUMBER 2 FOR REVISION NUMBER 7 REPORT DATE 2 PER BLOCK UP TO 18 - FACILITY NAME 8 OTHER FACILITIES INVOLVED 8 TOTAL - DOCKET NUMBER 3 IN ADDITION TO 05000 9 1 OPERATING MODE 10 3 POWER LEVEL ,
1 II REQUIREMENTS OF 10 CFR CHECK BOX THAT APPLIES 12 TO % M NAME LICENSEE CONTACT 14 FOR TELEPHONE CAUSE VARIES 2 FOR SYGJM 13 4 FOR COMPONENT EACH COMPONENT FAILURE !
4 FOR MANUFACTURER i NPRDS VARIES SUPPLEMENTA.L REPORT EXPECTED CHECK BOX THAT APPUES 15 EFECTED SUBMISSION DATE 2 PER BLOCK
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.NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY oMB NO. 3150-0104 r3 sa EXPIRES 5/31/95 ESTIVATED BJRDEN PER RESPONSE TO COMPLY WTH TH'S E%T'JS* &s'EniEN E'E5bOyOO?
LICENSEE EVENT REPORT (LER) E S A A EMENT B S
H BB7M4 TEXT CONTINUATION ^1RE t c, u s w r , S, THE PAPERWORK REDJCTON PRCLIECT (31S0 c104) OFFCE OF MANAGEMENT AND BJDGET, W ASMiNGTON, DC 20503 FACILITV NAME 0) DOCP ET NUMBE R (2) LER NUMBER (s) PAGE (3)
- bEQUENhAL REV;bCN g
NUMBER NUVBER oF HIVER BEAD STATION 05000 4 5 8 ~ ~
93 010 00 2 4 un ow n uv. . ,w a m .mm eoo,,, amRm,am o n REPORTED CONDITION On 05/14/93 with the plant in Opentional Condition 4 (Cold Shutdown), shutdown cooling (SDC) was lost for approximately thme minutes when one of the SDC suction valves closed. This occurred due to the initiation of a spurious engineered safety feature (ESF) actuation signal during de- ,
energization of a 120 VAC power distribution panel. Therefore, this repon is submitted pursuant to 10CFR50.73(b)(2)(iv) as an ESF actuation.
INVESTIGATION On 05/14/93, preparations were in progress to allow electrical maintenance to repair power line conditioner SCM*XRCl4A1. This power line conditioner supplies panel SCM*PNL01 A. This work was being done under maintenance work order (MWO) R158874. Operations Section Procedure (OSP)-0019, " Electrical Load Lists" (attachment 43 and enclosum 43), was being used to de-energize all loads on SCM*XRCl4A1. When breaker (*BKR*) #22 was opened, an isolation signal was generated that caused valve E12*MOVF008 (*20*) to close. This caused residual heat removal (RHR) pump "A" (*P*) to trip. Control room operators recognized immediately that shutdown cooling had been lost, and corrective actions were initiated. Breaker #22 on SCM*PNLOI A was closed, the isolation signal was reset, E12*MOVF008 was opened and RHR pump "A" was started to re-establish shutdown cooling. The pump trip occurred at 1310 and shutdown cooling was restored at 1313. The total time that shutdown cooling was not in service was three minutes.
Instrumentation in the control room indicated no rise in reactor coolant tempenture during this time period. Abnormal Operating Procedure (AOP)-0051, "Less of Decay Hea: Removal" was used to assist in restoring shutdown cooling and AOP-0003, " Automatic Isolations," was used to restore any other valves that would have closed when breaker #22 was opened. All other valves that would have closed from this ESF signal were already in the closed position due to plant conditions, with the exception of E12*MOVF053A, the shutdown cooling return valve. This valve was opened after RHR pump "A" was staned to re-establish flow to the reactor.
Operations Section Procedure (OSP)-0019 gives directions for compensatory measures to take when de-energizing electrical buses and panels. This procedure provides guidance for SCM*PNLOI A which had been independently reviewed by the Shift Supervisor, Control Operating Foreman and Shift Technical Advisor. All three individuals did not recognize the fact that measures were needed to prevent a loss of3hutdown cooling when opening breaker #22. Once shutdown cooling had been re-established, steps were taken to prevent isolation of the Division I shutdown cooling valves so that shutdown cooling would not be lost again. The de-energization of SCM*PNL0l A was then NRC FORM 366A (S Bh
D NRC FORM 366A u.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB No. 315(H)104 is et EXPIRES 5/31/95 (STtMATED BVRDFN PER RESPONSE TO COMPLY WlTH TH'S LICENSEE EVENT REPORT (LER) EMSiE2PRoINERo"ENMTih Eo@iNroa%%
TEXT CONTINUATION Qu"5$S c7v^$7'w2"No"o'"f** 73%,"sy,'"
THE PAPERWORK REDUCTION PROJECT (31504104). OFFICE 05 MANAGEMENT AND BUDGET WASHINGTON, D 20501 P ACILITY NAMf (1) DOCKET NUMBEM (2) LER NUMBER l$) - PAGE (3)
YEAR NUMBEA NUMBER 05000 458 RIVElt BEdD STATION 93 -
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TEK1 (!! most spect sg 99y90. u8t edQ@Ur@ C09tOS Of NRC f O!m XfsA} l17) completed with no other problems.
ROOT CAUSE The root cause of this incident was that on-shift management personnel missed the need for compensatory measums when opening breaker #22 to prevent a loss of SDC. This occurre<l during the reviews of attachment 43 and enclosure 43 to OSP-0019. Contributing factors to this oversight were as follows:
- 1. The compensatory measures to take for opening breaker #22 were very poorly written and led to improper interpretation of what actions needed to be taken. The recommendations for breaker #22 in enclosure 43 reference another procedure when actuation of components can occur if preventive measures are not taken. Information of this kind for all other breakers on SCM*PNL01 A is listed in enclosure 43.
- 2. The Shift Supervisor was too involved in the actual performance of this evolution, and therefore unable to maintain proper oversight during the implementation of OSP-0019.
A review of previous LERs revealed that LER 89-012 was similar. In LER 89-012, a loss of -
shutdown cooling occurred while an operator was hanging a clearance tag. The hanging of the cleamnce tag required the opening of breaker #20 on panel ISCM*PNL01B. Prior to the event, the Operator reviewed the power loss effect card. This card revealed that a reactor water cleanup system (RWCU) (*CE*) isolation would occer when the breaker was opened but did not make the Opemtor aware of the isolation of shutdown cooling.
CORRECTIVE ACTION ,
To prevent recurrence of this incident, the following corrective measures will be taken:
- 1. A change notice will be written for OSP-0019 attachment 43 and enclosure 43 to clearly state what valve will isolate on opening of breaker #22 on SCM*PNLOI A. ,
All needed information will be put in enclosure 43 such that there is no need to l
reference another procedure. Attachment 44 and enclosure 44 to OSP-0019 were also reviewed and the same problems are present for breaker #20 on SCM*PNIAlB. '
Enclosure 44 will also be changed by this change notice.
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l i NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. *150-0104 ,
EXPIRES 5/31/95 ESTWATED BJRDEN PER RESPONSE TO COM5'LY WTH THfS INFORMATION COdICTON REQUEST. 510 HRS. FORWARD COMMEms REaARa,No euRoEN EstuATE TO T-E wo MAroN e
LICENSEE EVENT REPORT (LER) AND P,ECORDS MANAGEMENT BRANCH (MNBS 7714)
TEXT CONTINUATION RcowoRy COMM ssoN wAs-Noyoy, oC m3 oo04. U.S. AN3 NUCLEAR 30 THE PAPERWORK REDUCTON PRNECT (31504104L OFFICE OF MANAGEMEN'T AND BJDGET, WASHtNGTON. DC 20503-DOCKET NUMBER (2) L1R NUMBER (4) PAGE p) 7 ACiuTV NAME (1)
LEQVENTiA 6 REV@ON NoMBER NUMBER 05000 OF RIVER BEND STATION 458 93 -
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- 2. A memo will be sent to all Shift Supervisors to remind them of the need to maintain proper oversight during evolutions. This memo will also emphasize the need to stop l other evolutions when performing a critical task if this is needed to prevent confusion.
- 3. This event will be included in the industry events training during mqualification training.
- 4. GSU will review applicable OSP-0019 guidance to identify additional cases in which l other procedures are referenced when compensatory measures are required. I Following this review, a supplemental report will be submitted by August 14,1993 to i document the findings.
SAFETY ASSESS 51ENT At the time shutdown cooling was lost, the plant had been shutdown since 04/17/93 at 1519 (27 days). The dumtion of the loss was minimal (3 minutes) and instmmentation indicated no change in reactor coolant temperature.
Note: Energy industry identification system codes are indicated in the text as (*XX*).
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