ML17263B059

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LER 95-003-00:on 950407,inadvertent Automatic SI Actuation Occurred When Technician Unblocked SIAS Due to Misleading Procedural Direction.Pressurizer Pressure Channel P-431 Bistable Proving Switch reinstated.W/950508 Ltr
ML17263B059
Person / Time
Site: Ginna Constellation icon.png
Issue date: 05/08/1995
From: MECREDY R C, ST MARTIN J T
ROCHESTER GAS & ELECTRIC CORP.
To: JOHNSON A R
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM), Office of Nuclear Reactor Regulation
References
LER-95-003, LER-95-3, NUDOCS 9505220005
Download: ML17263B059 (15)


Text

RIORITY1CCI'.LLTIUKTEDRll)SI'ROCI'.SSliG)REGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RXDS)ACCESSIONNBR:9505220005DOC.DATE:95/05/08NOTARIZED:NOFACIL:50-244RobertEmmetGinnaNuclearPlant,Unit1,RochesterGAUTH.NAMEAUTHORAFFILIATXONSTMARTIN,J.T.RochesterGas&ElectricCorp.MECREDY,R.C.RochesterGas&ElectricCorp.RECIP.NAMERECIPIENTAFFILIATIONJOHNSON,A.R.ProjectDirectorateI-1(PD1-1)(Post941001)

SUBJECT:

LER95-003-00:on950407,aninadvertentautomaticSIactuationoccurredwhentechnicianunblockedSIAS.Causedbymisleadingproceduraldir'ection.Automaticstartofengineeredsafeguardsinitiated.W/950508ltr.DISTRIBUTIONCODE:IE22TCOPIESRECEIVED:LTRjENCLiSIZE:TITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.DOCKET05000244NOTES:LicenseExpdateinaccordancewith10CFR2,2.109(9/19/72).05000244RECIPIENTIDCODE/NAMEPD1-1PDINTERNAL:AEODS~/BCENT/DEELBNRR/DISP/PIPBNRR/DRCH/HHFBNRR/DRCH/HOLBNRR/DSSA/SPSB/BRES/DSIR/EIBEXTERNAL:LSTLOBBYWARDNOACMURPHY,G.ANRCPDRCOPIESLTTRENCL112211111111111111111111RECIPIENTID'CODE/NAMEJOHNSON,AAEOD/SPD/RRABNRR/DE/ECGBNRR/DE/EMEBNRR/DOPS/OECBNRR/DRCH/HICBNRR/DSSA/SPLBNRR/DSSA/SRXBRGN1FILE01LITCOBRYCE,JHNOACPOORE,W.NUDOCSFULLTXTCOPIESLTTRENCL111111111111111111221111NYOTLT'I0ALL"RIDS"RECIPIENTS:PLE:KSEISELPI:STOREDUCEiVKSTE!CON'IACT'I'IIEDOC!.'if!IY'I'COi'TROI.DESk.ROO%1PI-37(EXT,504-T083)TOI;LIXIIiA1'I'.YOI:RiAi!L:I'i<OilDIS'I'RIIIIUI'IOY.LIS'I'SI'ORDOCI'ill'.X'I'SYOI.')OX"I'lI'.I)!FULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR26ENCL26 go~ANO.~RKH"STEkDASAIVD8'lk!CCORFOkATIOM89EASTAVEIVU,kCiwi,'>75k64n:i,)i;ROBERTC.MECREDYvicepscs~cc~le'u=iccrOvesct,cssMay8,1995U.S.NuclearRegulatoryCommission'ocumentControlDeskAttn:AllenR.JohnsonPWRProjectDirectorateI-1Washington,D.C.20555

Subject:

LER95-003,UnblockingofSafetyInjectionActuationSignalWhileatLowPressureConditions,DuetoMisleadingProceduralDirections,ResultsinInadvertentAutomaticSafetyInjectionActuationR.E.GinnaNuclearPowerPlantDocketNo.50-244Inaccordancewith10CFR50.73,LicenseeEventReportSystem,item(a)(2)(iv),whichrequiresareportof,"Anyeventorconditionthatresultedinamanualorautomaticactuationofanyengineeredsafetyfeature(ESF),includingthereactorprotectionsystem(RPS)",theattachedLicenseeEventReportLER95-003isherebysubmitted.Thiseventhasinnowayaffectedthepublic'shealthandsafety.Verytrulyours,RobertC.Mecredyxc:U.S.NuclearRegulatoryCommissionMr.AllenR.Johnson(MailStop14B2)PWRProjectDirectorateI-1Washington,D.C.20555U.S.NuclearRegulatoryCommissionRegionI475AllendaleRoadKingofPrussia,PA19406GinnaUSNRCSeniorResidentInspector2dsi/!9'505220005950508PDRADOCK05000244SPDR NRCFORM366(5.92)U.S.NUCLEARREGULATORYCOMHISSIONAPPROVEDBYOMBNO.3150-0104EXPIRES5/31/95L1CENSEEEVENTREPORT(LER)(Scereverseforrequirednumberofdigits/charactersforeachblock)ESTIHATEDBURDENPERRESPONSETOCOHPLY'WITHTHISINFORMATIONCOLLECTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHEINFORMATIONANDRECORDSMANAGEHENTBRANCH(HHBB7714),U.S.NUCLEARREGULATORYCOMMISSION,WASHIHGTON,DC20555-0001,AHDTOTHEPAPERWORKREDUCTIOHPROJECT(3150-0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FAcILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)05000244PAGE(3)10F12TITLE(4)UnblockingofSafetyInjectionActuationSignalWhileatLowPressureConditions,DuetoHisleadingProcedural'Directions,ResultsinInadvertentAutomaticSafetyInjectionActuationMONTHDAYYEAREVENTDATE(5)YEARLERNUMBER(6)SEQUENTIALNUMBERREVISIONNUHBERHONTHDAYYEARREPORTDATE(7)OTHERFACILITIESINVOLVED(8)DOCKETNUMBERFACILITYHAME04079595--003--000508FACILITYNAMEDOCKETNUMBEROPERATINGHODE(9)POWERLEVEL(10)N000THISREPORTISSUBHITTEDPURSUANT20.402(b)20.405(a)(1)(i)20.405(a)(1)(ii)20.405(a)(1)(iii)20.405(a)(1)(iv)20.405(a)(1)(v)20.405(c)50.36(c)('I)50.36(c)(2)50.73(a)(2)(i)50.73(a)(2)(ii)50.73(a)(2)(iii)50.73(a)(2)(iv)50.73(a)(2)(v)50.73(a)(2)(vii)50.73(a)(2)(viii)(A)50.73(a)(2)(viii)(B)50.73(a)(2)(x)73.71(b)73.71(c)OTHER(SpecifyinAbstractbelowandinText,NRCForm366A)e)(ll)TOTHERE(jUIREHENTSOF10CFR5:(CheckoneormorLICENSEECONTACTFORTHISLER(12)NAMEJohnT.St.Hartin-TechnicalAssistantTELEPHONENUMBER(IncludeAreaCode)(315)524-4446COHPLETEONELINEFOREACHCOHPONENTFAILUREDESCRIBEDINTHISREPORT(13)CAUSESYSTEHCOHPONENTHANUFACTURERREPORTABLETONPRDSCAUSESYSTEMCOHPONENTHANUFACTURERREPORTABLETONPRDSSUPPLEMENTALREPORTEXPECTED(14)YES(Ifyes,completeEXPECTEDSUBMISSIONDATE).EXPECTEDSUBMISSIONDATE(15)MONTHDAYYEARABSTRACT(Limitto1400spaces,i.e:,approximately15single-spacedtypewrittenlines)(16)OnApril7,1995atapproximately0900EDST,withtheplantinthecoldshutdownmodefortheannualrefuelingandmaintenanceoutage,aninadvertentautomaticSafetyInjectionActuationoccurredwhenatechnicianunknowinglyunblockedtheSafetyInjectionActuationSignalwithpressurizerpressureandsteamlinepressurelessthanthesetpointforSafetyInjectionActuation.Immediatecorrectiveactionwastomonitortheautomaticstartofengineeredsafeguardsfeaturescomponentsandsecureunneededequipment.TheunderlyingcauseoftheinadvertentautomaticSafetyInjectionActuationwasduetomisleadingproceduraldirection.ThiseventisNUREG-1022CauseCode(D).CorrectiveactiontoprecluderepetitionisoutlinedinSectionV.B.NRCFORM366(5-92)

NRCFORM366A(5.92)U.S.NUCLEARREGULATORYCOHHISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOHBNO.3150.0104EXPIRES5/31/95ESTIHATEDBURDENPERRESPONSETOCOHPLYWITHTHISINFORMATIOHCOLLECTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIHATETOTHEINFORMATIONANDRECORDSHANAGEHENTBRANCH(MHBB7714),U.S.NUCLEARREGULATORYCOMHISSION,WASHINGTON,DC20555-0001,AHDTOTHEPAPERWORKREDUCTIONPROJECT(3150.0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUMBER(2)05000244YEAR95LERNUMBER(6)SEQUENTIALM--003REVISIONPAGE(3)pp2OF12TEXT(Ifmorespaceisrequired,useadditionalcopiesofHRCForm366A)(17)PRE-EVENTPLANTCONDITIONS:Theplantwasinthecoldshutdownmodefortheannualrefuelingandmaintenanceoutage.Thereactorcoolantsystem(RCS)temperaturewasapproximately100degreesF,andtheRCSwasdepressurized.RCSlooplevelswereatapproximately80inches,whichisapartiallydrainedconditionwithwaterlevelfourinchesbelowthereactorvesselflange.OnApril6,1995,calibrationsofindividualinstrumentchannelsassociatedwithReactorProtectionSystem(RPS)Channel3werestartedforNuclearInstrumentSystem(NIS)channelN-43(usingcalibrationprocedureCPI-BISTABLES-N43),pressurizer(PRZR)pressurechannelP-431(usingcalibrationprocedureCPI-PT-431),andRCSAverageTemperaturechannelT-403(usingcalibrationprocedureCPI-TAVG-403).Thesechannelsweredefeatedinaccordancewithprocedures.ThecalibrationstepsofCPI-PT-431hadbeencompleted,buttheP-431channelcouldnotbereinstatedbecausereinstatementactivitiesalsorequiredthecompletionofcalibrationsofN-43andT-403,whichwerenotyetcompleted.Therefore,procedurestepsforreinstatingP-431werenotperformedatthistime.ThecalibrationsofN-43andT-403werecompletedonApril7'byteamsofInstrumentandControl(I&C)technicians.AnI&CtechnicianworkingintheControlRoomwasreadytoreinstatetheindividualinstrumentsassociatedwithRPSChannel3(N-43,P-431,andT-403).HehadalsobeenrequestedtosupporttheIGCtechniciansassignedtocalibratePRZRpressuresbydefeatingandreinstatingpressurechannels.TheIICtechniciansassignedtoPRZRpressureswereintheContainmentBuilding(CNMT)andrequestedtheIICtechnicianintheControlRoomtodefeatP-429,associatedwithRPSProtectionChannel1.TheIECtechniciansinCNMTandintheControlRoomdiscussedthesequenceofdefeatingandreinstating,andconcludedthatitwasmoreexpeditioustodefeattheP-429channelandproceedwithcalibrationofPT-429,thantowaitforreinstatementofN-43,P-431,andT-403beforedefeatingP-429.HRCFORH366A(592)

NRCFORM366A(5-92)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOMBNO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHEINFORMATIONAHDRECORDSMANAGEMENTBRANCH(MNBB7714),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555-0001,ANDTOTHEPAPERWORKREDUCTIONPROJECT(3150-0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKETNUMBER(2)05000244YEAR95LERNUMBER(6)SEQUENTIALUMREVISIONM--00300PAGE(3)3OF12TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)Onpreviouscalibrationsthatweek,andaspartofthe.pre-jobbriefingsonApril7,theIECtechnicianswereadvisedthattheycouldperformworkassociatedwithmorethanoneprotectionchannelatatimeatthisplantmode.Therefore,theyconcludedthatitwasacceptabletodefeatP-429first,andproceededwiththedefeatofP-429.Thecalibrationprocedure(CPI-PT-429)initialconditionsspecifiedthatOperationsperformanoperabilitycheckoftheotherPRZRpressurechannels(butonlyifRCStemperaturewasabove350degreesF).Temperaturewaslessthan350degreesF.Thus,theIICtechnicianintheControlRoommarkedthisstepas"Not'pplicable"("N/Au)anddidnotrequestthattheControlRoomoperatorsperformoperabilitychecksoftheotherPRZRpressurechannels.TheIECtechniciancontinuedwiththedefeatofP-429.Aspartofthecalibrationprocedure,theIICtechnicianhadtoobtainpermissionfromtheShiftSupervisorforthedefeatofP-429.TheControlRoomoperatorswereawarethatIECwouldbeperformingactivitiesassociatedwithmorethanoneRPSprotectionchannel,knewthat'thecalibrationstepsofCPI-PT-431hadbeencompleted,andassumedthattheP-431channelhadbeenreinstatedthepreviousday.Therefore,theControlRoomoperatorsgavetheIECtechnicianpermissiontodefeatchannelP-429.TheI&CtechnicianproceededtodefeatchannelP-429usingCPI-PT-429.II.DESCRIPTIONOFEVENT:A.DATESANDAPPROXIMATETIMESOFMAJOROCCURRENCES:April6,1995:I&CstartscalibrationsusingCPI-BISTABLES-N43,CPI-PT-431,andCPI-TAVG-403.April6,1995:IRCcompletescalibrationofP-431,butdoesnotreinstatetheP-431PRZRpressurechannel.April7,1995,0830EDST:IICcompletescalibrationsofN-43andT-403.April7,1995,0845EDST:IRCobtainspermissiontodefeatP-429PRZRpressurechannel.NRCFORM366A(5-92)

NRCFORH366A(5-92)U.S.NUCLEARREGULATORYCOHHISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOMBNO.3150~0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIONREOUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIHATETOTHEINFORMATIONANDRECORDSHANAGEMENTBRANCH(MNBB7714),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555-0001,ANDTOTHEPAPERWORKREDUCTIONPROJECT(3150-0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)YEAR050002449500300LERNUHBER(6)SEQUENTIALREVISIONPAGE(3)4OF12TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)April7,1995,0900EDST:Eventdateandtime.April7,1995,0900EDST:Discoverydateandtime.April7,1995,0908EDST:SafetyInjectionActuationandContainmentIsolationsignalsarereset.April7,1995,0915EDST:ContainmentVentilationIsolationsignalisreset.April7,1995,0930EDST:Pre-eventcoldshutdownconditionsarerestored.B.EVENT:Theplantwasinthecoldshutdownmodefortheannualrefuelingandmaintenanceoutage.TheRCStemperaturewasapproximately100degreesF,andtheRCSwasdepressurized.RCSlooplevelswereatapproximately80inches,whichisapartiallydrainedconditionwithwaterlevelfourinchesbelowthereactorvesselflange.OnApril7,1995,twoIRCtechnicianswereintheCNMTforperformanceofannualcalibrationofPRZRpressuretransmitters.AnotherI&CtechnicianwasintheControlRoomandwasassignedtoperformthedefeatingandreinstatingofthePRZRpressurechannels,asrequestedbythetechniciansinCNMT.TheI&CtechnicianintheControlRoomwasdefeatingchannelP-429usingcalibrationprocedureCPI-PT-429.Atapproximately0900EDST,theIECtechnicianintheControlRoomplacedtheSafetyInjection(SI)UnblockBistableProvingSwitch(BSPS)forP-429tothetrippedstate.TheSIActuationSignal(SIAS),isprovidedwithawhichpreventsaSIASfromoccurringforlowPRZRforlowsteamlinepressure.AtthistimeSIASwhichisanormalconfigurationwhenPRZRintentionallyreducedbelowtheSIASsetpoint.blocksignalpressureandwasblocked,pressureisNRCFORH366A(5-92)

NRCFORH366A(5.92)U.S.NUCLEARREGULATORYCOHHISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOMBNO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOHPLYWITHTHISINFORHATIONCOLLECTIONREQUEST:50.0NRS.FORWARDCOMMENTSREGARDINGBURDENESTIHATETOTHEINFORHATIONANDRECORDSMANAGEMENTBRANCH(HNBB7714),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555-0001ANDTOTHEPAPERWORKREDUCTIONPROJECT(3110-0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)YEAR0500024495LERNUHBER(6)SEQUENTIALM003REVISION00PAGE(3)5OF12TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)WiththeSIUnblockBSPSforchannelP-431stillinthetrippedstatefromcalibrationscompletedthepreviousday,thelogictoblockSIfromlowpressuresignalswasstillpresent.However,theSIASwasautomaticallyunblockedassoonastheP-429BSPSwasplacedinthetrippedstate.PRZRpressureandpressuresinboththe"A"and"B"steamgenerators(S/G)werebelowthesetpointforautomaticSIActuation,resultinginautomaticSIActuationfrom2/3LogicforPRZRpressurelessthan1750PSIGandfrom2/3LogicforS/Gpressurelessthan514PSIG.AutomaticSIActuationcausedautomaticactuationofCNMTIsolation(CI)andCNMTVentilationIsolation(CVI).AlloperableEngineeredSafeguardsFeatures(ESF)componentswereobservedtofunctionproperly,withtheexceptionofvalvepositionindicationforMOV-852B(RHRDischargetoReactorVesselDelugevalve).'hevalvepositionindicationforMOV-852Bdidnotindicatefulltraveltotheopenposition.However,subsequentinvestigationconfirmedthatthevalvedid,infact,traveltothe"fullopen"position.Allsafeguardsbussesremainedenergizedfromoff-sitepower.Duetoplantconditions,severalESFcomponentswerenotoperableatthestartofthisevent.The"B"D/Gwasinoperableforannualmanufacturerinspectionandoverhaul.AllthreeSIpumpswererenderedinoperable(startswitchin"pull-stop")tocomplywithGinnaTechnicalSpecifications(TS)requirementsforlowtemperatureRCSover-pressureprotection.Therefore,the"B"D/Gdidnotstart"andnoSIpumpsstarted.NoinjectionflowfromtheSIpumpstotheRCSoccurred.InitiallyoneResidualHeatRemoval(RHR)pumpwasinservice.ThesecondRHRpumpstartedduetotheSIAS.MOV-852AandMOV-852B(valvesforreactorvesseldelugefromRHRpumps)openedtoallowforRHRflowtothetopofthereactorvessel,aswellascontinuingRHRflowviathenormalshutdowncoolingflowpath.ThetotalRHRflowwasbeingcontrolledbyflowcontrolvalveFVC-626,sonosubstantialincreaseinRHRflowoccurred.TheRCSremainedstableattheinitialconditionsduringthiseventandalsoduringsubsequentrestorationactions.Nodisturbanceofprimarysystemconditionswasnoted.ThesecondRHRpumpwassecuredatapproximately0920EDST.NRCFORH366A(5-92)

NRCFORM366A(5.92)U.S.NUCLEARREGULATORYCOHHISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOHBNO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIOHREQUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIHATETOTHEINFORMATIONANDRECORDSMANAGEHENTBRANCH(MHBB7714),U.S.NUCLEARREGULATORYCOMHISSION,WASHINGTON,DC20555-0001,AHDTOTHEPAPERWORKREDUCTIONPROJECT(3150-0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.fACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)05000244LERNUMBER(6)YEARSEQUENTIAL95--003REVISIONNUMB00PAGE(3)6OF12TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)C.INOPERABLESTRUCTURES,COMPONENTS,ORSYSTEMSTHATCONTRIBUTEDTOTHEEVENT:PRZRpressurechannelP-431wasstilldefeatedfromcalibrationactivitiescompletedonApril6,1995,andwasinoperableatthestartoftheevent.D.OTHERSYSTEMSORSECONDARYFUNCTIONSAFFECTED:NoneE.METHODOFDISCOVERY:ThiseventwasimmediatelyapparentduetonumerousMainControlBoardAnnunciatoralarmsintheControlroom.F.OPERATORACTION:TheControlRoomoperatorsrespondedtotheAnnunciatoralarms,andnotedthatthestandbyRHRpumphadstartedandthatMotorControlCenter(MCC)1Ghadtripped.TheydiagnosedthatautomaticSIActuationhadoccurred,andverifiedthatallpreviouslyoperableESFcomponentsfunctionedproperly.NoimmediateactionswererequiredfortheRCS,sincereactorvesselwaterlevelandRHRflowindicationsremainedstable.AfterdeterminingthecauseoftheinadvertentautomaticSIAS,theControlroomoperatorsresettheSIASandCIandCVIsignals.Unneededequipmentwassecured.AllCIvalvesandCVIcomponents(whichchangedpositionduetotheSIAS)werereturnedtotheirpositionspriortotheevent.Pre-eventconditionswererestored.Subsequently,theControlRoomoperatorsnotifiedhighersupervisionandtheNRC.TheShiftSupervisornotifiedtheNRCOperationsCenterwithinfourhours,per10CFR50.72(b)(2)(ii).NRCFORH366A(5-92)

NRCFORM366A(5.92)U.S.NUCLEARREGULATORYCOHHISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOHBNO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIHATETOTHEINFORMATIONAHDRECORDS'HANAGEHENTBRANCH(HNBB7714),U.STNUCLEARREGULATORYCOMMISSION,WASHINGTON'C205550001iANDTOTHEPAPERWORKREDUCTIONPROJECT(3150-0104),OFFICEOFMAHAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)05000244LERNUHBER(6)SEQUENTIAL95--003REVISIONNUM00PAGE(3)7OF12TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)G.SAFETYSYSTEMRESPONSES:Allsafetysystemsandcomponentsthatwereoperablerespondedasdesigned,exceptthatthevalvepositionindicationforMOV-852Bdidnotindicatefulltraveltotheopenposition.AllotheroperableESFcomponentswereobservedtofunctionproperlyaftertheautomaticSIAS.III.CAUSEOFEVENT:*A.IMMEDIATECAUSE:TheimmediatecauseoftheinadvertentautomaticSIActuationwasbothfrom2/3logicfromPRZRpressureandfrom2/3logicfromS/GpressurewithSIASunblocked.B.INTERMEDIATECAUSE:TheintermediatecauseofautomaticSIASbeingunknowinglyunblockedwasplacingtheSIUnblockBSPSforP-429tothetrippedstatewiththesameBSPSforP-431alreadyinthetrippedstate.Thiswasaproceduralerrorandwasadirectresultofanerrorinanapprovedprocedure.CalibrationprocedureCPI-PT-429hadmisleadinginformation,inthatastepwastobemarked"N/A"ifRCStemperaturewaslessthan350degreesF.Markingthisstep"N/A"allowedtheI&CtechniciantotriptheP-429BSPSwithoutrequestingthattheControlRoomoperatorsverifythatthesameBSPSwasnottrippedintheotherPRZRpressurechannels.Withthisstepmarked"N/A",therewasnorequirementforIECtonotifytheControlRoomoperatorsthatP-431wasstilldefeatedwhenpermissionwasobtainedfromtheControlRoomoperatorstoperformthedefeatofP-429.NRCFORM366A(5-92)

NRCFORM366A(5-92)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOMBNO.3150.0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDIHGBURDENESTIMATETOTHEINFORMATIONANDRECORDSMANAGEMENTBRANCH(MNBB7714),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555-0001,ANDTOTHEPAPERWORKREDUCTIONPROJECT(3150-0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKETNUMBER(2)YEAR0500024495LERNUMBER(6)SEQUENTIAL003REVISIONPAGE(3)pp8OF12'EXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)AcontributingfactorwasthattheIKCtechnicianswerenotawarethatSIASwouldautomaticallyunblockwhentwoPRZRpressurechannelsweredefeatedatthesametime.TheIECtechniciansalsobelievedthatUnblockofSIwasnotaconcernattheseplantconditions,andwereunawareof'theconsequencesofunblockingSIattheseplantconditions.AnothercontributingfactorwasthattheControlRoomoperatorsweremadeawarethatI&CwouldbeperformingactivitiesassociatedwithmorethanoneRPSchannel,butdidnotaskwhichspecificchannelswouldbedefeatedsimultaneously.Theseactionswerebothcognitiveandproceduralerrorsandwerethedirectresultofanerrorinanapprovedprocedure.Therewerenounusualcharacteristicsoftheworklocation(ControlRoom)thatcontributedtotheerror.C.ROOTCAUSE:TheunderlyingcauseofthemisleadinginformationincalibrationprocedureCPI-PT-429wastheadditionofwordingthatidentifiedoperabilityrequirementsbaseduponTSTable3.5-2,Item1,whentheprocedurewasupgraded.OneofthestandardsfortheprocedureupgradewastomoreaccuratelyidentifytheTSissuesassociatedwithcalibrations.TheunderlyingcauseoftheimprecisevalvepositionindicationforMOV-852Bwasthesequenceofactuationofvalvelimitswitchrotors.Limitswitchcontactsononerotoractuatedtodeenergizethevalvemotorbeforelimitswitchcontactsonadifferentrotoractuatedtoextinguishthegreenlight(whichisintendedtoextinguishjustpriortothevalvereachingthefullyopenposition).ThiseventisNUREG-1022CauseCode(D),"DefectiveProcedure"~ThiseventdoesnotmeettheNUMARC93-01,"IndustryGuidelineforMonitoringtheEffectivenessofMaintenanceatNuclearPowerPlants",definitionofa"MaintenancePreventableFunctionalFailure",sincetherewasnofunctionalfailure.NRCFORM366A(5-92)

NRCFORH366A(5-92)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOMBNO.3150~0104EXPIRES5/31/95ESTIHATEDBURDENPERRESPONSETOCOMPLYWITHTHISIHFORMATIONCOLLECTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIHATETOTHEINFORHATIONANDRECORDSHANAGEMENTBRANCH(HNBB7714),U.S.NUCLEARREGULATORYCOHHISSION,WASHINGTON,DC20555-0001,ANDTOTHEPAPERWORKREDUCTIONPROJECT(3150-0104),OFFICEOFHANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)YEAR0500024495LERNUMBER(6)SEQUENTIAL003REVISIONNUM00PAGE(3)9OF12TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)IV.ANALYSISOFEVENT:Thiseventisreportableinaccordancewith10CFR50.73,LicenseeEventReportSystem,item(a)(2)(iv),whichrequiresareportof,"Anyeventorconditionthatresultedinamanualorautomaticactuationofanyengineeredsafetyfeature(ESF),includingthereactorprotectionsystem(RPS)".TheinadvertentautomaticSIActuationisanautomaticactuationofanESF.Anassessmentwasperformedconsideringboththesafetyconsequencesandimplicationsofthiseventwiththefollowingresultsandconclusions:TherewerenooperationalorsafetyconsequencesorimplicationsattributedtotheinadvertentautomaticSIActuationbecause:TheplantwasinthecoldshutdownmodewithhighheadSIpumpsrenderedinoperableinaccordancewithTS.TheRHRsystemwasalignedfordecayheatremoval,andS/Gnozzledamswereinplace.WithSIpumpsinoperable,theRCSwasnotsubjectedtoover-pressureconditionswhenoperableESFcomponentsstarted.TheRefuelingWaterStorageTankwasnotalignedtothesuctionoftheRHRpumps.Therefore,therewasnoadditionofwaterinventorytotheRCS.RCStemperaturecontinuedtobemaintainedstableviatheRHRsystem.Therefore,reactivitywasnotaffectedbyRCStemperaturechanges.TheServiceWaterSystem,ComponentCoolingWaterSystem,andSpentFuelCoolingSystemallremainedinserviceduringthisevent.WithSpentFuelCoolingremaininginservice,removalofdecayheatfromtheSpentFuelPoolwasassured.HRCFORH366A(5-92)

NRCFORH366A(5-92)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOMBNO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORHATIOHCOLLECTIONREQUEST:50.0HRS.FORWARDCOMHENTSREGARDINGBURDENESTIMATETOTHEINFORHATIONANDRECORDSHANAGEHENTBRANCH(MNBB7714),U.S.NUCLEARREGULATORYCOHMISSION,WASHINGTON,DC20555-0001,ANDTOTHEPAPERWORKREDUCTIONPROJECT(3150-0104),OFFICEOFHANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKETNUMBER(2)05000244LERNUMBER(6)YEARSEQUENTIAL95--003REVISIONUM00PAGE(3)10OF12TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)~TheRHRcoolingcapabilityremainedinserviceandRCSintegritywasmaintained.Therefore,heatremovalfromthereactorwasassured.~FlowthroughMOV-852Bwasnotlimitedduetovalveposition.Thevalvewas,infact,"fullopen",despitetheindication.Basedontheabove,itcanbeconcludedthatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVEACTION:A.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENTNORMALSTATUS:PRZRpressurechannelP-431BSPSwasreinstated(removedfromthetripmode),thusterminatingtheSIUnblocklogic,andallowingtheControlRoomoperatorstoagainblockSIAS.Afterthecauseoftheeventwasidentified,theSIAS,CI,andCVIsignalswerereset.Unneededectuipmentwassecured.MOV-852Bwasstroke-testedtothefullopenposition.AllCIvalvesandCVIcomponents(whichchangedpositionduetotheSIAS)werereturnedtotheirpositionspriortotheevent.Pre-eventconditionswererestored.B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:ATrainingWorkRequest(TWR)hasbeeninitiatedtoevaluatethetrainingforI&CtechniciansrelatingtoSIASinitiation.Pre-outagetrainingforIECtechnicianswillbeevaluatedfortheneedtoincludeESFandRPSlogic.CalibrationprocedureshavebeenreviewedtoidentifythosethathavethesamemisleadinginformationasCPI-PT-429.Procedureshavebeenchangedtoremovethemisleadinginformation.NRCFORM366A(5-92)

NRCFORH366A(5-92)U.S.NUCLEARREGULATORYCOHHISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOHBNO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDIHGBURDEHESTIMATETOTHEINFORMATIONANDRECORDSMANAGEHENTBRANCH(HNBB7714),U.S.NUCLEARREGULATORYCOHMISSIOH,WASHINGTON,DC20555-0001,ANDTOTHEPAPERWORKREDUCTIONPROJECT(3150-0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)05000244YEARLERNUHBER(6)SEQUENTIAL003REVI,SIONUM00PAGE(3)11OF12TDT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)MethodstovisuallyindicatetoControlRoomoperatorswhichinstrumentchannelsarebeingtestedoraredefeatedwillbeevaluated.ThelimitswitchpositionsforMOV-852Bwereadjustedtoensurethatthelimitswitchcontactstoextinguishthegreenlightactuatebeforethelimitswitchcontactsthatdeenergizethevalvemotor.LimitswitchactuationwasreviewedforotherMOVs,andthiswasdeterminedtobean'solatedcase.VI.ADDITIONALINFORMATION:A.FAILEDCOMPONENTS:NoneB.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistoricalsearchwasconductedwiththefollowingresults:LER84-006describedanautomaticactuationofSIAS.Duringplantheatup,PRZRpressurewasincreasedabovetheautomaticsetpointforunblockingSI,withS/GpressurestillbelowtheSIASsetpoint,duetooperatorerror.Thecorrectiveactiontopreventrecurrencewastoreviseoperatingproceduresforplantheatup.ThisactionwouldnothavepreventedLER95-003.LER85-004describedanautomaticactuationofSIAS.TheBSPSforonechannelofSIactuationwasinthetrippedstate.Duringaseparateactivity,aninstrumentbuswasinadvertentlydeenergized,causinganotherbistabletotrip,resultinginthelogicforSIAS.Thecorrectiveactiontopreventrecurrencewastoreviseprocedurestopreventtheinadvertentlossofpowertoinstrumentbusses'hisactionwouldnothavepreventedLER95-003.NRCFORH366A(5-92)

,ARM366A(5.92)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEOBYOMBNO.3150~0104EXPIRES5/31/95ESTIMATEDBURDEHPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDIHGBURDENESTIMATETOTHEINFORMATIONANDRECORDSMANAGEMENTBRANCH(MHBB7714),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555-0001,ANDTOTHEPAPERWORKREDUCTIONPROJECT(3150-0104),OFFICEOFMANAGEMENTANDBUDGETWASHIHGTOHDC20503.FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKETNUMBER(2)05000244YEAR95LERNUMBER(6)SEQUENTIALUM003REVISIONNUMB00PAGE(3)12OF12TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)LER89-003describedanautomaticactuationofSIAS.Simulatedsignals(abovetheSIASsetpoint)wereinsertedintotwoPRZRpressurechannels,causingSIAS.Thecorrectiveactiontopreventrecurrencewastoprovideclearerdirectiontotesttechnicianswhensimulatingsignals.ThisactionwouldnothavepreventedLER95-003.C.SPECIALCOMMENTS:NoneNRCFORM366A(5-92) 1