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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML20046C2121993-07-30030 July 1993 LER 93-004-01:on 930301,confirmed That Channel D Axial Shape Index (Asi) Being Calculated in Reverse Since 921031-930301 Due to Drawing Discrepancies Associated W/Control Channel B. Temporary Mod 92-078 & Standing Order 0-25 Revised ML20046A8691993-07-26026 July 1993 LER 93-011-00:on 930624,experienced Reactor Trip Due to Loss of Load.Caused by Lack of Proper Job Planning,Lack of Formal Decision Making Process & Incomplete Communications.Training Will Be Provided to Operations personnel.W/930726 Ltr ML20045H2561993-07-12012 July 1993 LER 93-010-00:on 930611,1 of 14 Halon Cylinders Did Not Meet Min Pressure Acceptance Criteria Listed in Semiannual Switchgear Rooms Surveillance Test.Caused by Failure of Test to Include Necessary Steps.Cylinder recharged.W/930712 Ltr ML20045D7201993-06-22022 June 1993 LER 93-009-00:on 930524,apparent Spurious Signal from Pressurizer Level Instrumentation Caused Backup Charging Pumps to Automatically Start,Due to Deterioration of Wiring. Instrument Loop Calibration Will Be performed.W/930622 Ltr ML20045D3741993-06-21021 June 1993 LER 93-008-00:on 930520,determined That TS SR Not Satisfied for Stack Flow Indicator,Per Amend 137 Issued on 910307. Caused by Lack of Attention to Detail.Calibr & Functional Test Procedures developed.W/930621 Ltr ML20044H5261993-06-0101 June 1993 LER 93-007-00:on 930430,unplanned Emergency Generator Start & Rt Signal Occurred.Caused by Inadequate Attention to Detail,Labeling of Fuse Drawers,Caution Signs & Training. Labeling & Caution Signs upgraded.W/930601 Ltr ML20044G4941993-05-26026 May 1993 LER 93-006-00:on 930118,Halon Fire Suppression Sys for Switchgear Rooms Disabled to Allow Repair/Replacement of Halon Sys Piping.On 930427,individual Responsible for Fire Watch Not Present.Individual Relieved of Responsibilities ML20044B6711993-02-22022 February 1993 LER 93-002-00:on 930122,determined That Current SG LP Signal Block Reset Values Greater than Allowed Ts.Caused by Improper Design.Test Procedures Will Be Revised by 930917 to Specify Desired Value for Block function.W/930222 Ltr ML20024G6821991-04-19019 April 1991 LER 91-007-00:on 910320,480 Volt Circuit Breaker Coordination Outside Design Basis.Caused by Deficiencies in Original Sys Design.Breaker/Fuse Coordination Study to Be Completed & Problems Will Be corrected.W/910419 Ltr ML20029C1591991-03-21021 March 1991 LER 91-004-00:on 910212,offsite Power Low Signal Outside Design Basis.Caused by Inadequate Mod Design at Time of Performance of Original Degraded Voltage Analysis. Engineering Analysis EA-FC-91-017 performed.W/910321 Ltr ML20029C1051991-03-18018 March 1991 LER 91-002-00:on 901209,ventilation Isolation Actuation Signal Generated by High Alarm on Process Radiation Monitor RM-062.Caused by Accumulation of Noncondensible Gases in Sample Piping.Valve Packing Leak repaired.W/910318 Ltr ML20029A2981991-02-0808 February 1991 LER 91-001-00:on 910109,determined That Containment Tendon Surveillances Performed in 1981 & 1985 Did Not Reflect Guidance in Tech Specs.Caused by Inadequate Administrative Controls.Testing Program Plan implemented.W/910208 Ltr ML20029A2971991-02-0606 February 1991 LER 90-022-02:on 900907,approx 460 Fire Barrier Penetration seals,60 Fire Dampers & 6 Fire Doors Declared Nonfunctional Per NRC Info Notice 88-004 Due to Lack of Documentation. Plant Outage Required to Implement Repairs/Replacements ML20028G9171990-09-28028 September 1990 LER 90-021-00:on 900829,inadvertent Reactor Protective Sys Actuation Occurred While Operator Changed Power Source. Caused by Operator Not Following Proper Procedures.Operator counseled.W/900928 Ltr ML20044B0131990-07-12012 July 1990 LER 90-018-00:on 900612,reactor Protective Sys (RPS) Trip Units for Axial Power Distribution Determined to Be Inoperable.Caused by Procedural Deficiencies.Procedure Revised & RPS Surveillance Tests reviewed.W/900712 Ltr ML20043F6301990-06-11011 June 1990 LER 90-016-00:on 900511,accident Scenarios Identified by Which Auxiliary Feedwater Piping from Discharge of Turbine Driven Auxiliary Feedwater Pump FW-10 Can Be Overpressurized.Caused by Design deficiency.W/900611 Ltr ML20043F2441990-06-0707 June 1990 LER 90-015-00:on 900507,PORV Variable Setpoints Used for Low Pressure Overpressure Protection Determined to Be Nonconservative for PORV Opening Time.Caused by Design Deficiency.Tech Spec Amend prepared.W/900607 Ltr ML20043C0991990-05-29029 May 1990 LER 90-014-00:on 900427,investigation Revealed That Component Cooling Water Piping to Reactor Coolant Pump Seal Coolers Could Be Targets of High Energy Line Break.Safety Analysis for Operability completed.W/900529 Ltr ML20042G7211990-05-10010 May 1990 LER 90-011-00:on 900402,inadvertent Actuation of Pressurizer Pressure Low Signal Occurred While Performing Calibr Procedure.Caused by Inappropriate Action by Technician Involved.Validation of Procedures reviewed.W/900510 Ltr ML20042E6871990-04-23023 April 1990 LER 90-007-01:on 900228,determined That Several Supports Would Be Overloaded During Seismic Event on Nonsafety Related & safety-related Main Steam Piping.Caused by Design Deficiency.Piping Supports modified.W/900423 Ltr ML20042E6861990-04-23023 April 1990 LER 90-009-00:on 900316,potential Overpressurization of Auxiliary Feedwater Piping Could Have Occurred During Thermal Expansion of Process Fluid Between Closed Valved. Caused by Design deficiencies.W/900423 Ltr ML20012E7641990-03-26026 March 1990 LER 90-005-00:on 900223,determined That Spent Fuel Pool Area Charcoal Filtration Unit VA-66 Was Outside Design Basis. Caused by Insufficient Airflow Into Unit.Affected Updated SAR Analysis Will Be updated.W/900326 Ltr ML20012D0121990-03-19019 March 1990 LER 90-004-00:on 900217,lift Pressures for 6 of 10 Main Steam Safety Valves Found Outside Acceptance Criteria. Caused by Overly Restrictive Operability Criteria.Valves Recalibr & License Amend Submitted to NRC.W/900319 Ltr ML20012D0101990-03-19019 March 1990 LER 90-003-00:on 900216,determined That Auxiliary Feedwater Piping Outside Normal Stress Limits of ASME Code & Design Basis Specified in Updated Sar.Caused by Design Deficiency.Valve Operators Will Be inspected.W/900319 Ltr ML20012B6361990-03-0909 March 1990 LER 89-017-01:on 890624,internal Valve Component from Check Valve Found Lying on Pump Discharge Vane.Repair or Replacement of Valve Internals Could Not Be Accomplished within Time Requirement of Tech Spec.W/900309 Ltr ML20006E1041990-02-0909 February 1990 LER 90-001-00:on 900108,fire Barrier for Wall Between Auxiliary Bldg Rooms 26 & 34 Breached But Hourly Fire Watch Patrol Not Established.Caused by Lack of Sufficient Training for Shift Supervisors.Standing Order revised.W/900209 Ltr ML20011E2691990-02-0505 February 1990 LER 89-024-00:on 891221,determined That Containment Spray Pumps & Suction Header Piping Not Constructed for Use as Backup to LPSI Sys for Shutdown Cooling.Caused by Inadequate Review of Assumptions.Firewatch established.W/900205 Ltr ML20011E2271990-02-0101 February 1990 LER 89-021-00:on 891010,util Informed by C-E of Potential Nonconservative Setpoint in Reactor Protection Sys Thermal Margin/Low Pressure Trip Unit.Caused by Error in Incorporating Transient Setpoint analyses.W/900201 Ltr ML20005F7151990-01-10010 January 1990 LER 89-023-00:on 891211,hourly Firewatch Patrol Entered Posted High Radiation Area W/O Meeting Entry Requirements for Area.Briefings on High Radiation Entry Requirements Held for Personnel W/Assigned dosimetry.W/900110 Ltr ML19354D6381989-12-20020 December 1989 LER 89-022-00:on 890805,change to Surveillance Procedure ST-CEA-1 Became Effective Which Would Have Made Both Emergency Diesel Generators Simultaneously Inoperable During Portion of Test.Change removed.W/891220 Ltr ML19332E7431989-12-0808 December 1989 LER 88-037-01:on 881214,one of Two Supply Headers Supplying Fire Suppression Headers in Auxiliary Bldg Isolated.Caused by Lack of Procedural Guidance & Inadequate Procedural Controls.Standing Order G-58 Will Be revised.W/891208 Ltr ML19332E2681989-12-0101 December 1989 LER 89-016-02:on 890616,for Unknown Period Since 890614, Auxiliary Feedwater Pump FW-10 Operated Outside Design Basis for Certain Accident Conditions.Caused by Inoperable Speed Control Loop.Action Plan implemented.W/891201 Ltr ML19351A4541989-11-22022 November 1989 LER 89-020-00:on 891012,determined That Two of Four Component Cooling Water HXs Simultaneously Inoperable for More than 24 H.Caused by Inadequate Controls Re Return of Equipment to Svc.Standing Order revised.W/891122 Ltr ML19327B5481989-10-24024 October 1989 LER 89-019-00:on 890924,indication of High Temp for Reactor Coolant Pump RC-3A Upper Motor Thrust Bearing Received in Control Room.Caused by Damaged Cable for Bearing Resistive Temp Device.Damaged Cable replaced.W/891024 Ltr ML19325D2471989-10-13013 October 1989 LER 89-012-01:on 890502,main Feedwater Isolation Valve to Steam Generator a Found Inoperable Due to Improperly Set Torque Switch.Caused by Inadequate Program for Maint of Motor Operated Valves.Torque Switches reset.W/891013 Ltr ML20028C7711983-01-0606 January 1983 LER 82-020/03L-0:on 821207,during Main Steam Safety Valve Test,Four Main Steam Safety Valves Had Lift Setpoints Out of Tolerance.Caused by Normal Drift of Valves Over Operating Cycle.Valves Readjusted ML20028B5451982-10-28028 October 1982 LER 82-019/03L-0:on 821024,MSIVs HCV-1041A & HCV-1042A Stopped Three to Four Degrees Off Seat When Signaled to Close.Caused by Binding Between Valve Packing & Shaft. Packings Sprayed W/Penetrant Oil ML20052J0631982-04-27027 April 1982 LER 82-009/03L-0:on 820411,while Exchanging Component Cooling Water Heat Exchangers,Associated Outlet Valves HCV-490B,HCV-491B & HCV-492B Failed to Open.Cause Not stated.HCV-491B Reassembled & Tested ML20052B2361982-04-0707 April 1982 LER 82-006/03L-0:on 820323,during Surveillance Test ST-ISI- WD-1,F.1,valve HCV-506A Failed to Close Via Control Room Switch.Caused by Solenoid Valve Malfunction.Solenoid Valve Disassembled,Cleaned & Reassembled ML20052D9291982-04-0606 April 1982 LER 82-008/03L-0:on 820330,during Performance of ST-FW-1, F.2(b)(6)per Tech Spec 3.9,steam Driven Auxiliary Feedwater Pump Failed to Start.Caused by Back Pressure Trip Lever in Tripped Position.Lever Reset ML20041G1291982-02-22022 February 1982 LER 82-005/03L-0:on 820210,at 98% Power,Control Element 24 Inserted Into Core.Emergency Procedure EP-13,CEDM Malfunctions,Implemented & Power Stabilized at 88%.Caused by Erroneous Operating Instruction.Instruction Changed ML20041F7481982-02-17017 February 1982 LER 82-003/03L-0:on 820203,containment Isolation Valve Associated W/Gas Vent Header HCV-507A Failed to Close on Demand.Caused by Solenoid Valve Plunger Sticking in Energized Position.Plunger Freed ML20041F6251982-02-0505 February 1982 LER 82-004/03L-0:on 820203,small Quantity of Radioactive Gas/Particulate Released to Auxiliary Bldg During Routine Operation.Caused by Failure of Stack Gas Monitor RM-062 to Alarm at Appropriate Setpoint Due to Faulty Alarm Module ML20041B1051982-01-28028 January 1982 LER 82-002/03L-0:on 820114,at 99% Power,Lockout Relay 86B1, Containment Radiation High Signal,Failed to Actuate on Demand by Plant Radiation Monitoring Sys.Caused by Burnt Coil on Lockout Relay.Coil Replaced & Tested Satisfactorily ML20041B1171982-01-19019 January 1982 LER 82-001/03L-0:on 820111,during Normal Operation,Two Fire Barrier Penetrations Found Nonfunctional.Shift Supervisor Immediately Notified;However,Fire Watch Not Posted.Insp & Supervisor Personnel Instructed on Proper Actions ML20039B4561981-12-11011 December 1981 LER 81-011/03L-0:on 811113,containment Isolation Valves Opened & Ventilation Process Initiated W/Containment Air Monitor RM-050/051 Inoperable.Caused by Personnel Error. Valves Closed ML20010H8581981-08-27027 August 1981 LER 81-008/03L-0:on 810813,86B/CRHS (Containment Radiation High Signal) Lockout Relay Failed to Actuate When RM-062 Was Placed in Alarm,Resulting in Failure of 86B1/CRHS Relay to Actuate.Caused by Dirt in Relay Latching Mechanism ML20041F6291981-08-27027 August 1981 LER 81-008/03L-1:on 810813,containment Radiation High Signal 86B Lockout Relay Failed to Actuate When Radiation Monitor RM-062 Placed in Alarm.Caused by Bound Relay Latching Mechanism Due to Dirt & Grease.Latch Cleaned ML20010C2271981-07-0707 July 1981 LER 81-006/03L-0:on 810624,reactor Protection Sys Nuclear Power Recorder Channel B Trip Setpoints Determined to Be Nonconservative.Caused by Faulty Temp Change Power Calculation Due to Grounded Hot Leg Temp Loop ML20004B1111981-05-0606 May 1981 LER 81-005/03L-0:on 810423,dc Sequencer Timers AC-3A (Component Cooling Water Pump) & AC-102A (Raw Water Pump) Failed to Time Out within Prescribed Limit.Cause Unknown Mechanisms Satisfactorily Inspected 1993-07-30
[Table view] Category:RO)
MONTHYEARML20046C2121993-07-30030 July 1993 LER 93-004-01:on 930301,confirmed That Channel D Axial Shape Index (Asi) Being Calculated in Reverse Since 921031-930301 Due to Drawing Discrepancies Associated W/Control Channel B. Temporary Mod 92-078 & Standing Order 0-25 Revised ML20046A8691993-07-26026 July 1993 LER 93-011-00:on 930624,experienced Reactor Trip Due to Loss of Load.Caused by Lack of Proper Job Planning,Lack of Formal Decision Making Process & Incomplete Communications.Training Will Be Provided to Operations personnel.W/930726 Ltr ML20045H2561993-07-12012 July 1993 LER 93-010-00:on 930611,1 of 14 Halon Cylinders Did Not Meet Min Pressure Acceptance Criteria Listed in Semiannual Switchgear Rooms Surveillance Test.Caused by Failure of Test to Include Necessary Steps.Cylinder recharged.W/930712 Ltr ML20045D7201993-06-22022 June 1993 LER 93-009-00:on 930524,apparent Spurious Signal from Pressurizer Level Instrumentation Caused Backup Charging Pumps to Automatically Start,Due to Deterioration of Wiring. Instrument Loop Calibration Will Be performed.W/930622 Ltr ML20045D3741993-06-21021 June 1993 LER 93-008-00:on 930520,determined That TS SR Not Satisfied for Stack Flow Indicator,Per Amend 137 Issued on 910307. Caused by Lack of Attention to Detail.Calibr & Functional Test Procedures developed.W/930621 Ltr ML20044H5261993-06-0101 June 1993 LER 93-007-00:on 930430,unplanned Emergency Generator Start & Rt Signal Occurred.Caused by Inadequate Attention to Detail,Labeling of Fuse Drawers,Caution Signs & Training. Labeling & Caution Signs upgraded.W/930601 Ltr ML20044G4941993-05-26026 May 1993 LER 93-006-00:on 930118,Halon Fire Suppression Sys for Switchgear Rooms Disabled to Allow Repair/Replacement of Halon Sys Piping.On 930427,individual Responsible for Fire Watch Not Present.Individual Relieved of Responsibilities ML20044B6711993-02-22022 February 1993 LER 93-002-00:on 930122,determined That Current SG LP Signal Block Reset Values Greater than Allowed Ts.Caused by Improper Design.Test Procedures Will Be Revised by 930917 to Specify Desired Value for Block function.W/930222 Ltr ML20024G6821991-04-19019 April 1991 LER 91-007-00:on 910320,480 Volt Circuit Breaker Coordination Outside Design Basis.Caused by Deficiencies in Original Sys Design.Breaker/Fuse Coordination Study to Be Completed & Problems Will Be corrected.W/910419 Ltr ML20029C1591991-03-21021 March 1991 LER 91-004-00:on 910212,offsite Power Low Signal Outside Design Basis.Caused by Inadequate Mod Design at Time of Performance of Original Degraded Voltage Analysis. Engineering Analysis EA-FC-91-017 performed.W/910321 Ltr ML20029C1051991-03-18018 March 1991 LER 91-002-00:on 901209,ventilation Isolation Actuation Signal Generated by High Alarm on Process Radiation Monitor RM-062.Caused by Accumulation of Noncondensible Gases in Sample Piping.Valve Packing Leak repaired.W/910318 Ltr ML20029A2981991-02-0808 February 1991 LER 91-001-00:on 910109,determined That Containment Tendon Surveillances Performed in 1981 & 1985 Did Not Reflect Guidance in Tech Specs.Caused by Inadequate Administrative Controls.Testing Program Plan implemented.W/910208 Ltr ML20029A2971991-02-0606 February 1991 LER 90-022-02:on 900907,approx 460 Fire Barrier Penetration seals,60 Fire Dampers & 6 Fire Doors Declared Nonfunctional Per NRC Info Notice 88-004 Due to Lack of Documentation. Plant Outage Required to Implement Repairs/Replacements ML20028G9171990-09-28028 September 1990 LER 90-021-00:on 900829,inadvertent Reactor Protective Sys Actuation Occurred While Operator Changed Power Source. Caused by Operator Not Following Proper Procedures.Operator counseled.W/900928 Ltr ML20044B0131990-07-12012 July 1990 LER 90-018-00:on 900612,reactor Protective Sys (RPS) Trip Units for Axial Power Distribution Determined to Be Inoperable.Caused by Procedural Deficiencies.Procedure Revised & RPS Surveillance Tests reviewed.W/900712 Ltr ML20043F6301990-06-11011 June 1990 LER 90-016-00:on 900511,accident Scenarios Identified by Which Auxiliary Feedwater Piping from Discharge of Turbine Driven Auxiliary Feedwater Pump FW-10 Can Be Overpressurized.Caused by Design deficiency.W/900611 Ltr ML20043F2441990-06-0707 June 1990 LER 90-015-00:on 900507,PORV Variable Setpoints Used for Low Pressure Overpressure Protection Determined to Be Nonconservative for PORV Opening Time.Caused by Design Deficiency.Tech Spec Amend prepared.W/900607 Ltr ML20043C0991990-05-29029 May 1990 LER 90-014-00:on 900427,investigation Revealed That Component Cooling Water Piping to Reactor Coolant Pump Seal Coolers Could Be Targets of High Energy Line Break.Safety Analysis for Operability completed.W/900529 Ltr ML20042G7211990-05-10010 May 1990 LER 90-011-00:on 900402,inadvertent Actuation of Pressurizer Pressure Low Signal Occurred While Performing Calibr Procedure.Caused by Inappropriate Action by Technician Involved.Validation of Procedures reviewed.W/900510 Ltr ML20042E6871990-04-23023 April 1990 LER 90-007-01:on 900228,determined That Several Supports Would Be Overloaded During Seismic Event on Nonsafety Related & safety-related Main Steam Piping.Caused by Design Deficiency.Piping Supports modified.W/900423 Ltr ML20042E6861990-04-23023 April 1990 LER 90-009-00:on 900316,potential Overpressurization of Auxiliary Feedwater Piping Could Have Occurred During Thermal Expansion of Process Fluid Between Closed Valved. Caused by Design deficiencies.W/900423 Ltr ML20012E7641990-03-26026 March 1990 LER 90-005-00:on 900223,determined That Spent Fuel Pool Area Charcoal Filtration Unit VA-66 Was Outside Design Basis. Caused by Insufficient Airflow Into Unit.Affected Updated SAR Analysis Will Be updated.W/900326 Ltr ML20012D0121990-03-19019 March 1990 LER 90-004-00:on 900217,lift Pressures for 6 of 10 Main Steam Safety Valves Found Outside Acceptance Criteria. Caused by Overly Restrictive Operability Criteria.Valves Recalibr & License Amend Submitted to NRC.W/900319 Ltr ML20012D0101990-03-19019 March 1990 LER 90-003-00:on 900216,determined That Auxiliary Feedwater Piping Outside Normal Stress Limits of ASME Code & Design Basis Specified in Updated Sar.Caused by Design Deficiency.Valve Operators Will Be inspected.W/900319 Ltr ML20012B6361990-03-0909 March 1990 LER 89-017-01:on 890624,internal Valve Component from Check Valve Found Lying on Pump Discharge Vane.Repair or Replacement of Valve Internals Could Not Be Accomplished within Time Requirement of Tech Spec.W/900309 Ltr ML20006E1041990-02-0909 February 1990 LER 90-001-00:on 900108,fire Barrier for Wall Between Auxiliary Bldg Rooms 26 & 34 Breached But Hourly Fire Watch Patrol Not Established.Caused by Lack of Sufficient Training for Shift Supervisors.Standing Order revised.W/900209 Ltr ML20011E2691990-02-0505 February 1990 LER 89-024-00:on 891221,determined That Containment Spray Pumps & Suction Header Piping Not Constructed for Use as Backup to LPSI Sys for Shutdown Cooling.Caused by Inadequate Review of Assumptions.Firewatch established.W/900205 Ltr ML20011E2271990-02-0101 February 1990 LER 89-021-00:on 891010,util Informed by C-E of Potential Nonconservative Setpoint in Reactor Protection Sys Thermal Margin/Low Pressure Trip Unit.Caused by Error in Incorporating Transient Setpoint analyses.W/900201 Ltr ML20005F7151990-01-10010 January 1990 LER 89-023-00:on 891211,hourly Firewatch Patrol Entered Posted High Radiation Area W/O Meeting Entry Requirements for Area.Briefings on High Radiation Entry Requirements Held for Personnel W/Assigned dosimetry.W/900110 Ltr ML19354D6381989-12-20020 December 1989 LER 89-022-00:on 890805,change to Surveillance Procedure ST-CEA-1 Became Effective Which Would Have Made Both Emergency Diesel Generators Simultaneously Inoperable During Portion of Test.Change removed.W/891220 Ltr ML19332E7431989-12-0808 December 1989 LER 88-037-01:on 881214,one of Two Supply Headers Supplying Fire Suppression Headers in Auxiliary Bldg Isolated.Caused by Lack of Procedural Guidance & Inadequate Procedural Controls.Standing Order G-58 Will Be revised.W/891208 Ltr ML19332E2681989-12-0101 December 1989 LER 89-016-02:on 890616,for Unknown Period Since 890614, Auxiliary Feedwater Pump FW-10 Operated Outside Design Basis for Certain Accident Conditions.Caused by Inoperable Speed Control Loop.Action Plan implemented.W/891201 Ltr ML19351A4541989-11-22022 November 1989 LER 89-020-00:on 891012,determined That Two of Four Component Cooling Water HXs Simultaneously Inoperable for More than 24 H.Caused by Inadequate Controls Re Return of Equipment to Svc.Standing Order revised.W/891122 Ltr ML19327B5481989-10-24024 October 1989 LER 89-019-00:on 890924,indication of High Temp for Reactor Coolant Pump RC-3A Upper Motor Thrust Bearing Received in Control Room.Caused by Damaged Cable for Bearing Resistive Temp Device.Damaged Cable replaced.W/891024 Ltr ML19325D2471989-10-13013 October 1989 LER 89-012-01:on 890502,main Feedwater Isolation Valve to Steam Generator a Found Inoperable Due to Improperly Set Torque Switch.Caused by Inadequate Program for Maint of Motor Operated Valves.Torque Switches reset.W/891013 Ltr ML20028C7711983-01-0606 January 1983 LER 82-020/03L-0:on 821207,during Main Steam Safety Valve Test,Four Main Steam Safety Valves Had Lift Setpoints Out of Tolerance.Caused by Normal Drift of Valves Over Operating Cycle.Valves Readjusted ML20028B5451982-10-28028 October 1982 LER 82-019/03L-0:on 821024,MSIVs HCV-1041A & HCV-1042A Stopped Three to Four Degrees Off Seat When Signaled to Close.Caused by Binding Between Valve Packing & Shaft. Packings Sprayed W/Penetrant Oil ML20052J0631982-04-27027 April 1982 LER 82-009/03L-0:on 820411,while Exchanging Component Cooling Water Heat Exchangers,Associated Outlet Valves HCV-490B,HCV-491B & HCV-492B Failed to Open.Cause Not stated.HCV-491B Reassembled & Tested ML20052B2361982-04-0707 April 1982 LER 82-006/03L-0:on 820323,during Surveillance Test ST-ISI- WD-1,F.1,valve HCV-506A Failed to Close Via Control Room Switch.Caused by Solenoid Valve Malfunction.Solenoid Valve Disassembled,Cleaned & Reassembled ML20052D9291982-04-0606 April 1982 LER 82-008/03L-0:on 820330,during Performance of ST-FW-1, F.2(b)(6)per Tech Spec 3.9,steam Driven Auxiliary Feedwater Pump Failed to Start.Caused by Back Pressure Trip Lever in Tripped Position.Lever Reset ML20041G1291982-02-22022 February 1982 LER 82-005/03L-0:on 820210,at 98% Power,Control Element 24 Inserted Into Core.Emergency Procedure EP-13,CEDM Malfunctions,Implemented & Power Stabilized at 88%.Caused by Erroneous Operating Instruction.Instruction Changed ML20041F7481982-02-17017 February 1982 LER 82-003/03L-0:on 820203,containment Isolation Valve Associated W/Gas Vent Header HCV-507A Failed to Close on Demand.Caused by Solenoid Valve Plunger Sticking in Energized Position.Plunger Freed ML20041F6251982-02-0505 February 1982 LER 82-004/03L-0:on 820203,small Quantity of Radioactive Gas/Particulate Released to Auxiliary Bldg During Routine Operation.Caused by Failure of Stack Gas Monitor RM-062 to Alarm at Appropriate Setpoint Due to Faulty Alarm Module ML20041B1051982-01-28028 January 1982 LER 82-002/03L-0:on 820114,at 99% Power,Lockout Relay 86B1, Containment Radiation High Signal,Failed to Actuate on Demand by Plant Radiation Monitoring Sys.Caused by Burnt Coil on Lockout Relay.Coil Replaced & Tested Satisfactorily ML20041B1171982-01-19019 January 1982 LER 82-001/03L-0:on 820111,during Normal Operation,Two Fire Barrier Penetrations Found Nonfunctional.Shift Supervisor Immediately Notified;However,Fire Watch Not Posted.Insp & Supervisor Personnel Instructed on Proper Actions ML20039B4561981-12-11011 December 1981 LER 81-011/03L-0:on 811113,containment Isolation Valves Opened & Ventilation Process Initiated W/Containment Air Monitor RM-050/051 Inoperable.Caused by Personnel Error. Valves Closed ML20010H8581981-08-27027 August 1981 LER 81-008/03L-0:on 810813,86B/CRHS (Containment Radiation High Signal) Lockout Relay Failed to Actuate When RM-062 Was Placed in Alarm,Resulting in Failure of 86B1/CRHS Relay to Actuate.Caused by Dirt in Relay Latching Mechanism ML20041F6291981-08-27027 August 1981 LER 81-008/03L-1:on 810813,containment Radiation High Signal 86B Lockout Relay Failed to Actuate When Radiation Monitor RM-062 Placed in Alarm.Caused by Bound Relay Latching Mechanism Due to Dirt & Grease.Latch Cleaned ML20010C2271981-07-0707 July 1981 LER 81-006/03L-0:on 810624,reactor Protection Sys Nuclear Power Recorder Channel B Trip Setpoints Determined to Be Nonconservative.Caused by Faulty Temp Change Power Calculation Due to Grounded Hot Leg Temp Loop ML20004B1111981-05-0606 May 1981 LER 81-005/03L-0:on 810423,dc Sequencer Timers AC-3A (Component Cooling Water Pump) & AC-102A (Raw Water Pump) Failed to Time Out within Prescribed Limit.Cause Unknown Mechanisms Satisfactorily Inspected 1993-07-30
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20217B5401999-10-0606 October 1999 Safety Evaluation Supporting Amend 193 to License DPR-40 ML20217A9931999-09-30030 September 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data LIC-99-0096, Monthly Operating Rept for Sept 1999 for Fcs,Unit 1.With1999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Fcs,Unit 1.With ML20211J9321999-09-0202 September 1999 Safety Evaluation Concluding That Licensee Proposed Alternatives Provide Acceptable Level of Quality & Safety. Proposed Alternatives Authorized for Remainder of Third ten- Yr ISI Interval for Fort Calhoun Station,Unit 1 LIC-99-0084, Monthly Operating Rept for Aug 1999 for Fort Calhoun Station.With1999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Fort Calhoun Station.With ML20216E6431999-08-26026 August 1999 Rev 19 to TDB-VI, COLR for FCS Unit 1 ML20210R1961999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Fcs,Unit 1 ML20210G2181999-07-27027 July 1999 Safety Evaluation Supporting Amend 192 to License DPR-40 ML20210D9951999-07-22022 July 1999 Safety Evaluation Supporting Amend 191 to License DPR-40 ML20216E6361999-07-21021 July 1999 Rev 18 to TDB-VI, COLR for FCS Unit 1 ML20210R2081999-06-30030 June 1999 Revised Monthly Operating Rept for June 1999 for Fcs,Unit 1 LIC-99-0065, Monthly Operating Rept for June 1999 for Fort Calhoun Station,Unit 1.With1999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Fort Calhoun Station,Unit 1.With ML20196H8621999-06-30030 June 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept ML20210P5461999-06-0808 June 1999 Rev 0,Vols 1-5 of Fort Calhoun Station 1999 Emergency Preparedness Exercise Manual, to Be Conducted on 990810. Pages 2-20 & 2-40 in Vol 2 & Page 4-1 in Vol 4 of Incoming Submittal Not Included ML20195B4581999-05-31031 May 1999 Rev 3 to CE NPSD-683, Development of RCS Pressure & Temp Limits Rept for Removal of P-T Limits & LTOP Requirements from Ts ML20207H7401999-05-31031 May 1999 Performance Indicators Rept for May 1999 LIC-99-0053, Monthly Operating Rept for May 1999 for Fort Calhoun Station,Unit 11999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Fort Calhoun Station,Unit 1 ML20195B4521999-05-17017 May 1999 Technical Data Book TDB-IX, RCS Pressure - Temp Limits Rept (Ptlr) ML20206L4241999-05-10010 May 1999 Safety Evaluation Supporting Corrective Actions to Ensure That Valves Are Capable of Performing Intended Safety Functions & OPPD Adequately Addressed Requested Actions Discussed in GL 95-07 ML20206M2601999-05-0606 May 1999 SER Concluding That Licensee IPEEE Complete Re Info Requested by Suppl 4 to GL 88-20 & IPEEE Results Reasonable Given FCS Design,Operation & History LIC-99-0047, Monthly Operating Rept for Apr 1999 for Fort Calhoun Station Unit 1.With1999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Fort Calhoun Station Unit 1.With ML20195E8621999-04-30030 April 1999 Performance Indicators, for Apr 1999 ML20205Q5831999-04-15015 April 1999 Safety Evaluation Supporting Amend 190 to License DPR-40 ML20210J4331999-03-31031 March 1999 Changes,Tests, & Experiments Carried Out Without Prior Commission Approval for Period 981101-990331.With USAR Changes Other than Those Resulting from 10CFR50.59 ML20206G2641999-03-31031 March 1999 Performance Indicators Rept for Mar 1999 LIC-99-0034, Monthly Operating Rept for Mar 1999 for Fcs,Unit 1.With1999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Fcs,Unit 1.With ML20205J8181999-02-28028 February 1999 Performance Indicators, for Feb 1999 LIC-99-0025, Monthly Operating Rept for Feb 1999 for Fort Calhoun Station,Unit 1.With1999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Fort Calhoun Station,Unit 1.With ML20207F3291999-01-31031 January 1999 FCS Performance Indicators for Jan 1999 ML20203B0991998-12-31031 December 1998 Performance Indicators for Dec 1998 LIC-99-0026, 1998 Omaha Public Power District Annual Rept. with1998-12-31031 December 1998 1998 Omaha Public Power District Annual Rept. with LIC-99-0003, Monthly Operating Rept for Dec 1998 for Fort Calhoun Station.With1998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Fort Calhoun Station.With ML20198S3771998-12-31031 December 1998 Safety Evaluation Supporting Amend 189 to License DPR-40 ML20198S4831998-12-31031 December 1998 Safety Evaluation Supporting Amend 188 to License DPR-40 ML20196G2251998-12-18018 December 1998 Rev 2 to EA-FC-90-082, Potential Over-Pressurization of Containment Penetration Piping Following Main Steam Line Break in Containment ML20198M3141998-11-30030 November 1998 Performance Indicators Rept for Nov 1998 LIC-98-0172, Monthly Operating Rept for Nov 1998 for Fort Calhoun Station,Unit 1.With1998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Fort Calhoun Station,Unit 1.With LIC-98-0160, Special Rept:On 981113,MSL RM RM-064 Was Declared Inoperable Due to Leakage Past Isolation Valve HCV-922.Troubleshooting Has Indicated That Leakage Has Stopped & Cause of Leak Continues to Be Investigated1998-11-25025 November 1998 Special Rept:On 981113,MSL RM RM-064 Was Declared Inoperable Due to Leakage Past Isolation Valve HCV-922.Troubleshooting Has Indicated That Leakage Has Stopped & Cause of Leak Continues to Be Investigated ML20203B0721998-11-16016 November 1998 Rev 6 to HI-92828, Licensing Rept for Spent Fuel Storage Capacity Expansion ML20196E4981998-10-31031 October 1998 Performance Indicators Rept for Oct 1998 ML20196G2441998-10-31031 October 1998 Changes,Tests & Experiments Carried Out Without Prior Commission Approval. with USAR Changes Other than Those Resulting from 10CFR50.59 LIC-98-0154, Monthly Operating Rept for Oct 1998 for Fort Calhoun Station,Unit 1.With1998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for Fort Calhoun Station,Unit 1.With ML20154M4881998-10-19019 October 1998 Safety Evaluation Supporting Amend 186 to License DPR-40 ML20154N2411998-10-19019 October 1998 Safety Evaluation Supporting Amend 187 to License DPR-40 LIC-98-0136, Monthly Operating Rept for Sept 1998 for Fort Calhoun Station,Unit 1.With1998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Fort Calhoun Station,Unit 1.With ML20155G4261998-09-30030 September 1998 Performance Indicators for Sept 1998 ML20154A1251998-08-31031 August 1998 Performance Indicators, Rept for Aug 1998 LIC-98-0122, Monthly Operating Rept for Aug 1998 for Fort Calhoun Station Unit 1.With1998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for Fort Calhoun Station Unit 1.With ML20238F7231998-08-17017 August 1998 Owner'S Rept for Isis 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 1999-09-30
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Omaha Public Power District P.O. Box 399 Hwy.75 - North of Ft. Calhoun Fort Calhoun, NE 680230399 l 402/636-2000 June 1, 1993 LIC-93-0064 ;
U. S. Nuclear Regulatory Commission Attn: Document Control Desk i Mail Station P1-137 Washington, DC 20555
Reference:
Docket No. 50-285 Gentlemen:
I
Subject:
Licensee Event Report 93-007 for the Fort Calhoun Station Please find attached Licensee Event Report 93-007 dated June 1, 1993. This report is being submitted pursuant to 10 CFR 50.73(a)(2)(iv). If you should have any questions, please cor. tact me. i Sincerely, iv f) bb W. G. Gates Vice President WGG/jrg Attachment c: J. L. Milhoan, NRC Regional Administrator, Region IV S. D. Bloom, NRC Project Manager R. P. Mullikin, NRC Senior Resident Inspector INP0 Records Center
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EVENT DATE (5) LER NUMBER (6) REPORT NUMBER (7) OTHER FACILITIES INVOLVED (8)
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UCENSEE CONTACT FOR THIS LER (12)
NAME TELEPHONE NUMBER pwude Area Coco)
Scott A. Lindquist, Shift Technical Advisor (402) 533-6829 COMPLETE ONE UNE FOR EACH COMPONENT FAILURE oESCRIBED IN THIS REPORT (13)
CAusE SYSTEM COMPONENT MANUFACTURER CAUSE SYSTEM COMPONENr MANUFACTUFER PRD TO l
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SUPPEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR j EXPECTED TEs SUBMISSION l Of yes, compee EXPECTED BUO2SSON DATE) X N DATE (15)
ABSTRACT (Umit to 1400 spaces, i.e., approximately 15 single-Spaced typewritten lines) (16)
On April 30, 1993 at approximately 1019 CDT, with the Fort Calhoun Station in Hot Shutdown (Mode 3), a non-licensed operator was performing an independent verification of the return-to-service positions of equipment which had previously been taken.out of service for maintenance. While intending to verify the installation of potential transformer fuses for Transformer T1A-1, the individual pulled the drawer with the .
potential transformer fuses for 4160V Bus 1A1. This resulted in a Bus 1Al low voltage l alarm, an automatic start of Emergency Diesel Generator DG-1 and load shedding of '
Bus 1A1 (including tripping of Reactor Coolant Pump RC-3A). Actual voltage on Bus 1Al remained normal. The tripping of RC-3A resulted in a subsequent Low Reactor Coolant Flow reactor trip signal.
The causes of the event were determined to be inadequate attention to detail, inadequate labeling of the fuse drawers, inadequate caution signs and inadequate training.
Corrective actions will include upgrading of labeling and caution signs for 4160V cubicles and training for operators on potential transformer fuses.
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NUMBER NUMBER l Fort Calhoun Station Unit No. 1 05000285 2 OF 5 l 93 -- 007 -- 00 i
TDCT (it more space is required, une addthonal copies of NRC Form 306A) (17)
BACKGROUND l
The Fort Calhoun Station (FCS) 4160V electrical distribution system includes four I separate 4160V buses. Unit Auxiliary Buses 1A1 and 1A2 feed large auxiliary loads j directly at 4160V. House Service Buses 1A3 and 1A4 feed the remainder of the 4160V ;
components as well as supplying power to all 480V plant loads through 4160/480V '
transformers. Engineered safeguards loads are powered via Buses 1A3 and 1A4, either directly or through 480V load centers. Buses 1A3 and 1A4 may each be supplied from an emergency diesel generator.
The 4160V electrical distribution system is equipped with an undervoltage relay protection scheme which is designed to ensure that adequate voltage exists on station buses to permit safe reactor shutdown and maintain the reactor in a safe shutdown condition under all grid conditions. Indication of a loss of voltage initiates a load shed signal which opens breakers on the affected bus to prevent overloading an incoming supply and initiates an automatic start of the associated emergency diesel generator.
The Reactor Protective System (RPS) monitors certain critical plant operating parameters and compares them to predetermined setpoints. If one or more of the monitored parameters reaches its setpoint on two of the four channels, the RPS will initiate a ,
reactor trip. There are twelve different reactor trips that can be initiated from the !
RPS. The trip unit of interest for this event is the Low Reactor Coolant Flow reactor l trip. l The low flow trip provides protection against departure from nucleate boiling should ,
coolant flow suddenly decrease significantly. The trip setpoint is 95% of nominal core flow. Shutdown or loss of one or more reactor coolant pumps will initiate a Low Reactor Coolant Flow RPS signal.
EVENT DESCRIPTION On the morning of April 30, 1993, with FCS in Hot Shutdown (Mode 3) for a short duration planned outage, a non-licensed operator was directed to perform an independent verification of the return-to-service positions of equipment which had previously been taken out of service for maintenance. The maintenance had involved a synchronizing potential transformer in the 345kV system. Earlier that day, potential transformer fuses had been reinstalled by an electrician.
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Fort Calhoun Station Unit No. 1 05000285 3 OF 5 93 -- 007 -- 00 TEXT (If more space is required, use addluonal copies of NRC Fomt 366A) (17)
After reviewing the tag sheet, the operator performing the independent verification began by verifying the return-to-service position of the feeder breaker to Bus 1A1. He then intended to locate and verify the installation of the potential transformer fuses for Transformer T1A-1. He began by looking for fuses in the Dus 1Al feeder breaker cubicle (Cubicle 1Al-7). Next, as he closed the Cubicle 1Al-7 door, he noticed a sign on the adjacent cubicle (Cubicle 1Al-6) which read, " Pulling PT Fuses Will De-Energize Bus 1Al". The operator then opened the door to Cubicle 1Al-6, which houses the potential transformer fuses for Bus 1Al rather than the potential transformer fuses for Transformer T1A-1. The operator was under the mistaken impression that this cubicle might contain the fuses that he was trying to locate. :
1 Inside Cubicle 1Al-6, the operator noticed a drawer which he knew to contain fuses. l There was also an additional caution sign which indicated that pulling fuses would de-energize the bus. The operator overlooked a small label on the outside of the drawer which identified the fuses in the drawer. The operator pulled the drawer out to look for fuse labels and saw no labels inside the drawer. The drawer was then shut. A low .
voltage alarm was received in the Control Room for Bus 1Al at this time, which cleared )
shortly thereafter. l The operator then returned to the IA1 feeder breaker cubicle (Cubicle 1Al-7) to re-verify that it did not contain any fuses. He then went back to Cubicle 1Al-6 to re-examine it. Approximately twenty seconds after initially pullir.g the drawer, he pulled the drawer again. This time the drawer was pulled out long enough to initiate load shedding of Bus 1A1 in addition to the low voltage alarm in the Control Room. (There is i a two second time delay prior to initiation of load shedding.) The indication of low voltage on Bus 1Al resulted in an automatic start of Emergency Diesel Generator DG-1, and initiated load shedding which tripped Reactor Coolant Pump RC-3A and Circulating Water Pump CW-1A (which are both powered from Bus 1A1). Actual voltage remained normal on the bus. The tripping of RC-3A resulted in a subsequent Low Reactor Coolant Flow reactor trip signal at 1019 CDT.
Following the reactor trip signal, Emergency Operating Procedures E0P-00, " Standard Post Trip Actions," and E0P-01, " Reactor Trip Recovery," were completed and plant systems were returned to their normal alignment.
The NRC was notified of this event on April 30, 1993 at 1323 CDT pursuant to 10CFR50.72(b)(2)(ii). This report is being submitted pursuant to 10CFR50.73(a)(2)(iv).
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FADUTY NAME (1) D00 MET NUMBER R LER NUMBEM M h PAGE R NUMB Fort Calhoun Station Unit No. 1 05000285 4 OF 5 l 93 --
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'l The affect of this event on plant safety was minimal. Engineered safety features i functioned as designed in response to the event. Actual voltage remained normal on J
, Bus 1A1 in spite of the low voltage alarm, load shedding and diesel generator start. .i
! Also, Bus 1A1 does not supply power to engineered safeguards loads.
I The plant was in Hot Shutdown with all control rods fully inserted at the time of this event. Therefore, while the tripping of Pump RC-3A resulted in a low Reactor Coolant i Flow RPS signal, the plant was in a condition in which the RPS low flow trip is not required (i.e., Technical Specifications allow this trip to be bypassed below 1.0 E-4%
power). ,
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l CONCLUSIONS
, A Human Performance Evaluation System review identified the following causes as l contributing to this event. ,
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.A . Inadequate Attention to Detail - The operator was attempting to verify the installation of potential transformer fuses for Transformer T1A-1, but was not in the correct cubicle. The potential transformer fuses for Transformer T1A-1 are located in Cubicle 1Al-8 which was labeled " Potential XFMR and Ground Fault Locator Compartment Transformer TIA-1 Secondary". The operator pulled the drawer in Cubicle 1Al-6 which was labeled " Potential XFMR Compartment' 4160 VAC Bus 1Al". The tag sheet for the fuses to be verified had correctly listed the location of the fuses as Cubicle 1Al-8.
B. Inadequate Labeling of the Fuse Drawers - These fuses are not labeled l adequately. The small label was overlooked by the operator.
C. Inadequate Caution Signs - The operator was misled by the caution sign hanging L on the outside of the cubicle door which stated " Pulling P. T. Fuses Will De-Energize Bus IAl". The operator believed that pulling the fuses from the drawer, rather than pulling the drawer, would de-energize the bus.
D. Inadequate Training - Operations personnel are not currently trained on the location or operation of potential transformer fuses, although per Standing Order 0-20, they may be required to perform the independent verification of these components.
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FACILRY NAME (1) DOC *ET NUMBER R LER NUMBER R PAGE R SEQUENTML HEVISION yg NUMBER NUMBER Fort Calhoun Station Unit No. 1 05000285 93 -- 007 -- 00
'TtxT p ,no,. .n.c. aoi,.a. u mon.i oe Nac rorm asea 3 cit 3 CORRECTIVE ACTIONS The following corrective actions have been or will be completed:
- 1. The operator was counseled on the need for attention to detail and was involved in the preparation of a video tape to be used for training on the event. (See Corrective Action 4.) ,
- 2. The labeling of electrical equipment located inside 4160V cubicles will be <
inspected during the 1993 Refueling-Outage to identify specific. labeling changes needed to more clearly identify the equipment contained within the cubicle. Ap3ropriate labels will then be procured and installed no later than the end of t1e following refueling outage.
- 3. The caution signs on the outside of 4160V cubicles containing potential transformer fuses have been upgraded to clarify that pulling the fuse drawer rather than pulling the fuse will cause a trip of-the associated component (s).
- 4. Training will be provided to operators on the location and operation of potential transformer fuses which they may be required to verify. Training will also be provided on this event, emphasizing the need for attention to detail. This action will be completed by September 10, 1993.
PREVIOUS SIMILAR EVENTS LER 87-009 reported a loss of off-site power during a refueling shutdown, due to inadvertently pulling the wrong potential transformer fuses.
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