LER-1980-002, /03L-0:on 800116,during Fuel Bundle Clip Insp,Fuel Bundle UD-3-023 Was Misoriented & Was Not Properly Seated in Core Cell Location.Caused by Personnel Error & Inadequate Procedural Controls.Procedure 205 Revised |
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On January 16, 1980, during a fuel bundle clip inspection prior to fuel 1
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180* and was not properly seated in core cell location 05-74. This I
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Fuel bundle UD3-023 was inspected for fuel rod clad failure by the fuel j
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The cause of this event is attributed to personnel error and to inad-
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Procedure 205 " Reactor Refueling" has been
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NAME OF ?REPARER
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Jersey Central Power & Ught Company i.d (-r,f * *,*J,[,
Madison Avenue at Punch Bowl Road un
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Morristown, New Jersey 07960 (201)455-8200 OYSTER CREEK NUCLEAR GENERATING STATION Forked River, New Jersey 08731 Licensee Event Report Reportable Occurrence No. 50-219/80-2/3L Report Date February 15, 1980 Occurrence Date January 16, 1980 Identification of Occurrence Operation with a misoriented fuel assembly during cycle Vlil.
This event is considered to be a reportable occurrence as defined in the Techni-cal Specifications, paragraph 6.9.2.b. (3).
Conditions Prior to Occurrence The plant was shutdown for refueling and maintenance.
Description of Occurrence On January 16, 1980, at approximately 6: 00 a.m., during a fuel bundle clip inspection prior to fuel " sipping", it was discovered that fuel bundle UD3-023 was misoriented 180* and was not properly seated in its core cell location 05-14.
Apparent Cause of Occurrence Operator error, procedural controls and error on the part of other personnel involved in the refueling activity, contributed to the cause of this event.
. Analysis of Occurrence A review of cycle 8 power distributions indicate a maximum cycle bundle radial power of 0.63 Utilizing " worst case" peaking factors (1.57 axial and 1.277 local) would result in a bundle CPR of 2.54 If UD3-023 was correctly orientated.
An analysis discussed in Facility Change Request #4,Section V. A.2, January 18, 1973, determined that a 7 x 7, type lilF fuel bundle misoriented 180* would result in a 21% increase to the bundle local peaking.
This increase indicates Jersey Central Power & Light Company is a Member of the General Pubhc Utthfies Systern
Reportable Occurrence No. 50-219/80-2/3L Page 2 February 15, 1980 that the minimum CPR of bundled UD3-023 in its misoriented position was 2.23 -
which is considerably above the Technical Specification operating limit of 1.64.
In addition, fuel bundle UD3-023 was inspected for fuel rod clad failure by the fuel vacuum sipping method. The inspection concluded that no clad failure had occurred.
Fuel Assembly UD3-023 was discharged from the core as scheduled.
Further, core cell 05-14 is located at a low flux peripheral core area.
A letter from R. E. Engel (General Electric) to D. G. Eisenhut (NRC), " Fuel Assembly Loading Error", dated November 30, 1977, states that a fuel loading error in a low flux peripheral core location is not significant.
Therefore, since analysis concludes the CPR of the misoriented fuel bundle is considerably above the technical specification operating limit CPR, an inspec-tion of the fuel bundle determined no fuel clad failure, and the determination that a misoriented fuel bundle in a low flux core peripheral location is insig-nificant, the safety significance of the occurrence is considered minimal.
A critical review of operator methods and procedural controls utilized during final fuel loading and bundle orientation verification was conducted. The review indicated that operator methods of determining bundle orientation is inadequate in that no procedural guidance or core map displaying the proper orientation of each bundle is utilized.
Although the proper orientation of non-peripheral bundles is easily determined by the repeatable pattern of control cell markings, peripheral bundles are located at the edge of the marking pattern and some bundles are not included in any control ceII.
This discontinuous area of orientation marking pattern increases the margin for fuel bundle orientation error.
The review also indicates that the operator methods and procedural control of core verification could be improved.
Fuel bundle orientation verification is conducted, (as required by procedure) utilizing a video monitoring system.
The camera associated with the monitor system is not stabilized during bundle orien-tation verification and its " free swinging" ability produces shadows and other distortions to the TV monitor.
These distorted visual effects decrease the ability to perform a proper bundle orientation verification and increases the probability of a bundle orientation verification error. Althouth video monitoring conditions are not totally conducive to bundle orientation verification, procedure 1001.24, " Core Verification", required only one verification of proper bundle orientation.
Corrective Action
The fol1< wing procedural controls will be implemented to insure the occurrence will not be repeated.
(1)
Procedure 205, " Reactor Refueling" has been revised to include the use of a " Fuel Bundle Orientation" map to be utilized during fuel loading.
Reportable Occurrence No. 50-219/80-2/3L Page 3 February 15, 1980 (2)
Procedure 1001.24, " Core Verification" will be revised to include:
(a) documentation of bundle orientation during verification of fuel bundle identification numbe.s.
(b) If possible fuel bundle orientation verification will be video taped, and (c) Quality Assurance personnel will perform an independent orientation verification in addition to the verification (s) required above.
Additionally, there will be a requirement that the Video Monitoring System be modified such that a
" stabilized" video display will be produced during bundle orientation verification.
Failure Data Not applicable.
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| 05000219/LER-1980-001-01, /01T-o:on 800105,while Performing Electromatic Relief Valve Operability Test,Emergency Releie Valve D Failed to Open.Caused by Component Failure Due to Retainer Ring Being Backed Off Approx Six Threads | /01T-o:on 800105,while Performing Electromatic Relief Valve Operability Test,Emergency Releie Valve D Failed to Open.Caused by Component Failure Due to Retainer Ring Being Backed Off Approx Six Threads | | | 05000219/LER-1980-001, Forwards LER 80-001/01T-0 | Forwards LER 80-001/01T-0 | | | 05000219/LER-1980-002-03, /03L-0:on 800116,during Fuel Bundle Clip Insp,Fuel Bundle UD-3-023 Was Misoriented & Was Not Properly Seated in Core Cell Location.Caused by Personnel Error & Inadequate Procedural Controls.Procedure 205 Revised | /03L-0:on 800116,during Fuel Bundle Clip Insp,Fuel Bundle UD-3-023 Was Misoriented & Was Not Properly Seated in Core Cell Location.Caused by Personnel Error & Inadequate Procedural Controls.Procedure 205 Revised | | | 05000219/LER-1980-002, Forwards LER 80-002/03L-0 | Forwards LER 80-002/03L-0 | | | 05000219/LER-1980-003-01, /01T-0:on 800116,during Inservice Insp on Core Spray Sparger Piping for Sys Ii,Two Indications of Cracks Discovered.Ultrasonic Test Revealed through-wall Cracks. Possibly Caused by Sparger Installation Method | /01T-0:on 800116,during Inservice Insp on Core Spray Sparger Piping for Sys Ii,Two Indications of Cracks Discovered.Ultrasonic Test Revealed through-wall Cracks. Possibly Caused by Sparger Installation Method | | | 05000219/LER-1980-003, Forwards LER 80-003/01T-0 | Forwards LER 80-003/01T-0 | | | 05000219/LER-1980-004, Forwards LER 80-004/03L-0 | Forwards LER 80-004/03L-0 | | | 05000219/LER-1980-004-03, /03L-0:on 800125,on 800125,29 & 0213,radioactive Water Discovered Leaking from Severely Pitted Aluminum Piping of Condensate Transfer Sys.Caused by Galvanic Corrosion.Leaks Temporarily Repaired & Piping to Be Replaced | /03L-0:on 800125,on 800125,29 & 0213,radioactive Water Discovered Leaking from Severely Pitted Aluminum Piping of Condensate Transfer Sys.Caused by Galvanic Corrosion.Leaks Temporarily Repaired & Piping to Be Replaced | | | 05000219/LER-1980-005, Forwards LER 80-005/03L-0 | Forwards LER 80-005/03L-0 | | | 05000219/LER-1980-005-03, /03L-0:on 800205,during Weekly Surveillance of Standby Gas Treatment Sys,Setpoints for Radiation Monitors RNO4A-1 & RNO4A-2 Found to Read Less Conservatively than Tech Spec.Caused by Personnel Error & Instrument Drift | /03L-0:on 800205,during Weekly Surveillance of Standby Gas Treatment Sys,Setpoints for Radiation Monitors RNO4A-1 & RNO4A-2 Found to Read Less Conservatively than Tech Spec.Caused by Personnel Error & Instrument Drift | | | 05000219/LER-1980-006-03, /03L-0:on 800131,during Reactor Recirculation Flow Calibr surveillance,as-found Values of Recirculation Flow Sensors at Zero Percent Simulated Flow Were Out of Tolerance.Caused by Instrument Drift | /03L-0:on 800131,during Reactor Recirculation Flow Calibr surveillance,as-found Values of Recirculation Flow Sensors at Zero Percent Simulated Flow Were Out of Tolerance.Caused by Instrument Drift | | | 05000219/LER-1980-006, Forwards LER 80-006/03L-0 | Forwards LER 80-006/03L-0 | | | 05000219/LER-1980-007-03, /03L-0:on 800213,while Performing 10-h Test on Standby Gas Treatment Sys 1,flow Was Less than Tech Spec Limit.Caused by Slipping Drive Belts on Exhaust Fan EF1-8. Drive Belts Replaced | /03L-0:on 800213,while Performing 10-h Test on Standby Gas Treatment Sys 1,flow Was Less than Tech Spec Limit.Caused by Slipping Drive Belts on Exhaust Fan EF1-8. Drive Belts Replaced | | | 05000219/LER-1980-007, Forwards LER 80-007/03L-0 | Forwards LER 80-007/03L-0 | | | 05000219/LER-1980-008-01, /01T-0:on 800215,during Insp for IE Bulletin 79-14,discovered Nine Pipe Clamps Installed W/O Restraining Welded Lugs.Caused by Oversight During Const.Welded Lugs to Be Installed | /01T-0:on 800215,during Insp for IE Bulletin 79-14,discovered Nine Pipe Clamps Installed W/O Restraining Welded Lugs.Caused by Oversight During Const.Welded Lugs to Be Installed | | | 05000219/LER-1980-008, Forwards LER 80-008/01T-0 | Forwards LER 80-008/01T-0 | | | 05000219/LER-1980-009-03, During Annual Insp of Containment Spray Heat Exchanges,Leaks Discovered in Four Heat Exchangers.Caused by Component Failure & Design.Heat Exchangers to Be Retubed W/Titanium | During Annual Insp of Containment Spray Heat Exchanges,Leaks Discovered in Four Heat Exchangers.Caused by Component Failure & Design.Heat Exchangers to Be Retubed W/Titanium | | | 05000219/LER-1980-009, Forwards Revised LER 80-009/03L-1 | Forwards Revised LER 80-009/03L-1 | | | 05000219/LER-1980-010, Forwards LER 80-010/01T-0 | Forwards LER 80-010/01T-0 | | | 05000219/LER-1980-010-01, /01T-0:on 800220,during IE Bulletin 79-14 Insp, Pipe hangers,NP-2-R8A & NP-2-R8B Found Improperly Installed. Cleanup Sys Restraint Mod & Nonrigid Restraint Added | /01T-0:on 800220,during IE Bulletin 79-14 Insp, Pipe hangers,NP-2-R8A & NP-2-R8B Found Improperly Installed. Cleanup Sys Restraint Mod & Nonrigid Restraint Added | | | 05000219/LER-1980-010-03, /03L-1:on 790417,excavation Was Started to Repair Leak Near Inside Penetration within Pipe Tunnel.Activity Was Detected in Soil Near Dedt Line.Dedt Line Rerouted on 800316.Line Will Be Repaired | /03L-1:on 790417,excavation Was Started to Repair Leak Near Inside Penetration within Pipe Tunnel.Activity Was Detected in Soil Near Dedt Line.Dedt Line Rerouted on 800316.Line Will Be Repaired | | | 05000219/LER-1980-011-03, /03L-0:on 800219,during Surveillance Test,Trip Occurred on Standby Gas Treatment Sys 1.Caused by Cracked Flow Sensing Line Which Was Probably Stepped On.Line Replaced | /03L-0:on 800219,during Surveillance Test,Trip Occurred on Standby Gas Treatment Sys 1.Caused by Cracked Flow Sensing Line Which Was Probably Stepped On.Line Replaced | | | 05000219/LER-1980-011, Forwards LER 80-011/03L-0 | Forwards LER 80-011/03L-0 | | | 05000219/LER-1980-012, Forwards LER 80-012/03L-0 | Forwards LER 80-012/03L-0 | | | 05000219/LER-1980-012-03, /03L-0:on 800228,discovered That Weekly Surveillance Tests for Main Station & Diesel Generator Batteries Not Performed During Seventh Wk.Caused by Error in Personnel.Evaluation Will Be Made to Determine Improvements | /03L-0:on 800228,discovered That Weekly Surveillance Tests for Main Station & Diesel Generator Batteries Not Performed During Seventh Wk.Caused by Error in Personnel.Evaluation Will Be Made to Determine Improvements | | | 05000219/LER-1980-013, Forwards LER 80-013/01T-0 | Forwards LER 80-013/01T-0 | | | 05000219/LER-1980-013-01, /01T-0:on 800309,fire Suppression Water Sys Removed from Svc to Replace Cracked Valve,Contrary to Tech Specs.Fire Truck Pumper Used as Water Supply Backup. Cause of Valve Body Crack Under Investigation | /01T-0:on 800309,fire Suppression Water Sys Removed from Svc to Replace Cracked Valve,Contrary to Tech Specs.Fire Truck Pumper Used as Water Supply Backup. Cause of Valve Body Crack Under Investigation | | | 05000219/LER-1980-014-01, /01T-0:on 800302,emergency Diesel Generator 1 Failed to Synchronize & Tripped When Generator 2 Was Tagged for Mod.Caused by Component Failure.Fuse F7,found Loose in Holder.Fuseholder Repaired | /01T-0:on 800302,emergency Diesel Generator 1 Failed to Synchronize & Tripped When Generator 2 Was Tagged for Mod.Caused by Component Failure.Fuse F7,found Loose in Holder.Fuseholder Repaired | | | 05000219/LER-1980-014, Forwards LER 80-014/01T-0 | Forwards LER 80-014/01T-0 | | | 05000219/LER-1980-015, Forwards LER 80-015/03L-0 | Forwards LER 80-015/03L-0 | | | 05000219/LER-1980-015-03, /03L-0:on 800403,piston Rod on Closure Mechanism for Reactor Bldg Ventilation Automatic Isolation Valve Was Found Broken,Making Valve Inoperable.Caused by Component Failure.New Piston Rod Eye Stud Was Fabricated & Installed | /03L-0:on 800403,piston Rod on Closure Mechanism for Reactor Bldg Ventilation Automatic Isolation Valve Was Found Broken,Making Valve Inoperable.Caused by Component Failure.New Piston Rod Eye Stud Was Fabricated & Installed | | | 05000219/LER-1980-016, Forwards LER 80-016/01T-0 | Forwards LER 80-016/01T-0 | | | 05000219/LER-1980-016-01, /01T-0:on 800512,util Recognized That 800420 Discovery of Defective Pressure Switch,Psl D,Constituted Immediate Rept.Caused by Cocked Teflon Actuator.Switch Removed & Will Be Replaced | /01T-0:on 800512,util Recognized That 800420 Discovery of Defective Pressure Switch,Psl D,Constituted Immediate Rept.Caused by Cocked Teflon Actuator.Switch Removed & Will Be Replaced | | | 05000219/LER-1980-017-01, /01T-0:on 800516,while Performing Control Rod Interference checks,green-green Rod Position Indication Remained Illuminated While Withdrawing Rod 10-23.Caused by Operator & Procedure in Bypass & Component Failure | /01T-0:on 800516,while Performing Control Rod Interference checks,green-green Rod Position Indication Remained Illuminated While Withdrawing Rod 10-23.Caused by Operator & Procedure in Bypass & Component Failure | | | 05000219/LER-1980-017, /03L-0:on 800520,during Investigation of LER 80-17/1T, One Rod Free Travel Interlock Surveillance Requirements Not Performed as Required.Causec by Failure to Perform Procedure & Schedule Surveillance | /03L-0:on 800520,during Investigation of LER 80-17/1T, One Rod Free Travel Interlock Surveillance Requirements Not Performed as Required.Causec by Failure to Perform Procedure & Schedule Surveillance | | | 05000219/LER-1980-018-03, /03L-0:on 800507,during Monthly Surveillance Testing of Reactor High Pressure Scram sensors,RE03D Found to Be Less Conservative than Specified.Caused by Sensor Repeatability.Sensor Reset | /03L-0:on 800507,during Monthly Surveillance Testing of Reactor High Pressure Scram sensors,RE03D Found to Be Less Conservative than Specified.Caused by Sensor Repeatability.Sensor Reset | | | 05000219/LER-1980-018, Forwards LER 80-018/03L-0 | Forwards LER 80-018/03L-0 | | | 05000219/LER-1980-020, Forwards LER 80-020/01T-0 | Forwards LER 80-020/01T-0 | | | 05000219/LER-1980-020-01, /01T-0:on 800605,following Insp of Fire Barriers Protecting safety-related Areas,Several Penetrations Found in Degraded Condition.Caused by Deficiencies in Installation Specs & Personnel Error Re Delay in Establishing Watche | /01T-0:on 800605,following Insp of Fire Barriers Protecting safety-related Areas,Several Penetrations Found in Degraded Condition.Caused by Deficiencies in Installation Specs & Personnel Error Re Delay in Establishing Watches | | | 05000219/LER-1980-021, Has Been Cancelled | Has Been Cancelled | | | 05000219/LER-1980-022-03, /03L-0:on 800603,reactor High Pressure Isolation Condenser Initiation Switch Trip Points Found Less Conservative than Specified.Caused by Unusual Svc Condition. Pressure Switches Reset & Exercised to Ensure Operation | /03L-0:on 800603,reactor High Pressure Isolation Condenser Initiation Switch Trip Points Found Less Conservative than Specified.Caused by Unusual Svc Condition. Pressure Switches Reset & Exercised to Ensure Operation | | | 05000219/LER-1980-022, Forwards LER 80-022/03L-0 | Forwards LER 80-022/03L-0 | | | 05000219/LER-1980-023, Forwards LER 80-023/03L-0 | Forwards LER 80-023/03L-0 | | | 05000219/LER-1980-023-03, /03L-0:on 800523,prior to Inservice Insp Reactor Vessel Hydro,Testing Revealed That Electromatic Relief Valve High Pressure Sensor IA83B Exceeded Tech Spec Setpoint. on 800531,sensor IA83F Found to Exceed Setpoint | /03L-0:on 800523,prior to Inservice Insp Reactor Vessel Hydro,Testing Revealed That Electromatic Relief Valve High Pressure Sensor IA83B Exceeded Tech Spec Setpoint. on 800531,sensor IA83F Found to Exceed Setpoint | | | 05000219/LER-1980-024, Forwards LER 80-024/03L-0 | Forwards LER 80-024/03L-0 | | | 05000219/LER-1980-025, Forwards LER 80-025/01T-0 | Forwards LER 80-025/01T-0 | | | 05000219/LER-1980-025-01, /01T-0:on 800618,during Surveillance Test, Nonfunctioning Operator Discovered in Valves V-9-12 & V-9-8 Found Leaking.Caused by Component Failure.Defective Valves Replaced & Will Be Inspected.Revised Rept Will Follow | /01T-0:on 800618,during Surveillance Test, Nonfunctioning Operator Discovered in Valves V-9-12 & V-9-8 Found Leaking.Caused by Component Failure.Defective Valves Replaced & Will Be Inspected.Revised Rept Will Follow | | | 05000219/LER-1980-026, Forwards LER 80-026/03L-0 | Forwards LER 80-026/03L-0 | | | 05000219/LER-1980-026-03, /03L-0:on 800709,during Routine Testing Insp of Hydraulic Snubbers Installed in safety-related Sys,Snubber 75/5 Failed to Lock Up in Compression Direction.Caused by Foreign Matl in Snubber Fluid.Snubber Flushed & Refilled | /03L-0:on 800709,during Routine Testing Insp of Hydraulic Snubbers Installed in safety-related Sys,Snubber 75/5 Failed to Lock Up in Compression Direction.Caused by Foreign Matl in Snubber Fluid.Snubber Flushed & Refilled | | | 05000219/LER-1980-027, Forwards LER 80-027/01T-0 | Forwards LER 80-027/01T-0 | |
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