ML17263A551

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LER 94-003-00:on 940208,open Instrument Tube Resulted in Loss of Containment Integrity.Caused by Personnel Error. Swagelok Plug Installed on Open tube.W/940310 Ltr
ML17263A551
Person / Time
Site: Ginna Constellation icon.png
Issue date: 03/10/1994
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-94-003, LER-94-3, NUDOCS 9403170001
Download: ML17263A551 (11)


Text

ACCELERATEDDISTRIBUTIONDEMONSTPA.TIONSYSTEM~~REGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ACCESSXONNBR:9403170001DOC.DATE:94/03/10NOTARIZED:NOFACIL:50-244RobertEmmetGinnaNuclearPlant,Unit1,RochesterGAUTH.NAMEAUTHORAFFILIATIONST.MARTIN,J.T.RochesterGas6ElectricCorp.MECREDY,R.C.RochesterGas6ElectricCorp.RECXP.NAMERECIPIENTAFFILIATIONJOHNSON,A.R.ProjectDirectorateI-3I

SUBJECT:

LER94-003-00:on940208,openinstrumenttuberesultedinlossofcontainmentintergrity.Causedbypersonnelerror.Swagelokpluginstalledonopentube.W/940310ltr.DISTRIBUTXONCODE:IE22TCOPIESRECEIVED:LTRENCLSIZETITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.NOTES:LicenseExpdateinaccordancewith10CFR2,2.109(9/10/72).DOCKET0500024405000244RECIPIENTIDCODE/NAMEPD1-3PDINTERNAL:AEOD/DOAAEOD/ROAB/DSPNRR/DE/EMEBNRR/DRCH/HHFBNRR/DRCH/HOLBNRR/DRSS/PRPBNRR/DSSA/SRXBRES/DSIR/EIBEXTERNAL:EG&GBRYCE,J.HNRCPDRNSXCPOORE,W.COPIESLTTRENCL111122111111221'1'221111RECIPIENTIDCODE/NAMEJOHNSON,AAEOD/DSP/TPABNRR/DE/EELBNRR/DORS/OEABNRR/DRCH/HICBNRR/DRIL/RPEBN~S@jh/PLBGILE02RGN1FILE01LSTLOBBYWARDNSICMURPHY,G.ANUDOCSFULLTXTCOPIESLTTRENCL111111111111111111111=111P2lg7lgyg~NOTETOALL"RIDS"RECIPIENTS:PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELIMINATEYOURNAMEFROMDISTRIBUTIONLISTSFORDOCUMENTSYOUDON'TNEED!FULL'TEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR27ENCL27 ROCHESTERGASANDELECTRICCORPORATIONirr~~Mii~*r'j";Torrisrrrr~89EASTAVENUE,ROCHESTERN.Y.14649-0001ROBERTCiLECREDYVicePresidenlOinnaNuclearProducrionTELEPHONEArrEACOOE7l65462700March10,1994U.S.NuclearRegulatoryCommissionDocumentControlDeskAttn:AllenR.JohnsonProjectDirectorateI-3Washington,D.C.20555

Subject:

LER94-003,UninstalledSwagelokTubingPlug,DuetoPersonnelError,CausesaLossofContainmentIntegrityR.E.GinnaNuclearPowerPlantDocketNo.50-244Inaccordancewith10CFR50.73,LicenseeEventReportSystem,items(a)(2)(i)(B)and(a)(2)(v),whichrequireareportof,"Anyoperationorconditionprohibitedbytheplant'sTechnicalSpecifications",and"Anyeventorconditionthatalonecouldhavepreventedthefulfillmentofthesafetyfunctionofstructuresorsystemsthatareneededtocontrolthereleaseofradioactivematerialormitigatetheconsequencesofanaccident",theattachedLicenseeEventReportLER94-003isherebysubmitted.Thiseventhasinnowayaffectedthepublic'shealthandsafety.Verytrulyyours,RobertC.Mecredyxc:U.S.NuclearRegulatoryCommissionRegionI475AllendaleRoadKingofPrussia,PA19406GinnaSeniorResidentInspector9403170001940310PDRADOCK050002446PDR(>(H7(a(r~(itlj NRCFORH366(5-92)U.SNUCLEARREGULATORYCQOIISSIONAPPROVEDBY(NBNO3150-0104EXPIRES5/31/95LICENSEEEVENTREPORT(LER)Iv'Seereverseforrequirednumberofdigits/charactersforeachblock)ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIOHREQUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHEINFORMATIOHANDRECORDSMANAGEMEH1'RAHCH(MNBB7714),U.S.NUCLEARREGULATORYCOMMISSION,'WASHINGTOH,DC205550001ANDTOTHEPAPERWORKREDUCTIONPROJECT(31i0-0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FAclLITYMANE(1)R.E~GinnaNuclearPowerPlantDOCKETNNGIER(2)05000244PAGE(3)10F0TITLE(4)UninstalledSwagelokTubingPlug,DuetoPersonnelError,CausesaLossofContairwentIntegrityEVENTDATE5MONTHDAYYEAR2894YEAR94LERNQIBER6SEQUENTIALNUMBER--003--REPORTDATE7REVISIONNUNBERMONTHDAYYEAR000310FACILITYNAMEDOCKETNUMBERFACILITYNAMEDOCKETNUMBEROTHERFACILITIESINVOLVED8OPERATINGN(X)E(9)POWERLEVEL(10)N098THISREPORTISSUBMITTEDPURSUANT20.402(b)20.405(a)('l)(i)20.405(a)(1)(ii)20.405(c)50.36(c)(1)50.36(c)(2)50.73(a)(2)(iv)50.73(a)(2)()50.73(a)(2)(vii)73.71(b)73.71(c)OTHERTOTHEREQUIREMENTSOF10CFR:Checkoneormore1120.405(a)(1)(iii)20.405(a)(1)(iv)20.405(a)(1)(v)X50.73(a)(2)(i)50.73(a)(2)(ii)50.73(a)(2)(iii)LICENSEECONTACTFORTHISLER'1250.73(a)(2)(viii)(A)50.73(a)(2)(viii)(B)50.73(a)(2)(x)(SpecifyinAbstractbelowandinText,NRCForm366ANAMEJohnT.St.Hartin-Director,OperatingExperienceTELEPHONENUMBER(IncludeAreaCode)(315)524-4446C(NPLETEONELINEFOREACHC(NPONENTFAILUREDESCRIBEDINTHISREPORT13CAUSESYSTEMCOMPONENTMANUFACTURERREPORTABLETOHPRDSCAUSESYSTEHCOMPONENI'ANUFACTURERREPORTABLETOHPRDSSUPPLENENTALREPORTEXPECTED14YES(lfyes,ccepleteEXPECTEDSUBHISSIONDATE).XNOEXPECTEDSUBIIISSIONDATE(15)MONTHDAYYEARABSTRACT(Limitto1400spaces,i.e.,approximately15single-spacedtypewrittenlines)(16)OnFebruary8,1994,atapproximately1020EST,withthereactoratapproximately98'.steadystatepower,anInstrumentandControltechnicianobservedanopeninstrumenttube.EventreconstructiondeterminedthatthisopentubehadresultedinalossofContainmentintegrityonNovember18,,1993.Immediatecorrectiveactionwastoinstallaswagelokplugontheopentube.Theunderlyingcauseoftheopentubewasapersonnelerroronthepartofaplanttechnician.(ThiseventisNUREG-1022(A)causecode.)CorrectiveactiontoprecluderepetitionisoutlinedinSectionV(B).HRCFORM366(5-92)

HRCFORM366A(5-92)U.S.NICLEARREGULATORYCQIIISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYQCIHO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIONREOUEST:50.0HRS.FORWARDCOMMENTSREGARDINCBURDENESTIMATETOTHEINFORMATIONANDRECORDSMAHAGEMEHTBRANCH(MHBB7714),U.S.NUCLEARREGULATORYCOMMISSIOH,WASHINGTON,DC20555-0001ANDTOTHEPAPERWORKREDUCTIONPROJECT(3140-010C),OFFICEOFMANACEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAME1R.E.GinnaNuclearPowerPlantDOCKETNNBER2YEAR0500024494LERNUMBER6SEOUENTIALM--003REVISION00PACE32OF8TEXT(lfmorespaceisrequired,useadditionalcopiesofHRCForm366A)(17)PRE-EVENTPLANTCONDITIONSTheplantwasatapproximately98%steadystatereactorpower.InstrumentandControl(I&C)departmentpersonnelwereperformingcalibrationprocedureCPI-PI-70.5,"CalibrationofPlantFieldMountedPressureGauges",onpressureindicatorPI-2281,"ContainmentEquipmentHatchPressure".ThisworkisperformedoutsideofContainment,intheareaoftheContainment(CNMT)EquipmentHatch.II-DESCRIPTIONOFEVENTA.DATESANDAPPROXIMATETIMESOFMAJOROCCURRENCES:November12,1993,1600EST:Basedonrecordsreview,itwasconcludedthataswagelokplugwasnotreinstalledinaccordancewithasurveillancetestprocedurecompletedonthisdateandtime.November18,1993,0457EST:Eventdateandtime.February8,1994,1020EST:Discoverydateandtime.February8,1994,1030EST:I&Ctechnicianinstallsswagelokplugonopentube,eliminatingthepotentialforalossofCNMTintegrity.February8,1994,1630EST:Reportabilitydateandtime.B.EVENT:OnFebruary8,1994,atapproximately1020EST,withthereactoratapproximately98'teadystatereactorpower,I&CtechnicianswerepreparingtoperformcalibrationprocedureCPI-PI-70.5onPI-2281.AnI&Ctechnicianobservedanearbyinstrumenttubethathadanopenend,andrecognizedthatthetubenormallyhasaswagelokpluginstalled.Theplugwassittingonaledgeapproximatelysix(6)inchesfromtheopentubing.(Thetechniciandidnotobserveanyotherplugsmissinginthearea.)Henotifiedhissupervision(theI&Cforeman)andwasdirectedbytheforemantoinstalltheplug.HRCFORM366A(592)

NRCFORH366A(5-92)U.SNUCLEARREGULATORYCQHISSIOHLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBY(HIBNO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIOHREQUEST:50.0HRS.FORWARDCOMMENTSREGARDIHGBURDENESTIMATETOTHEINFORMATIONANDRECORDSMANAGEMEHTBRANCH(MHBB7714),U.S.HUCLEARREGULATORYCOMMISSION,WASHINGTON,DC205550001ANDTOTHEPAPERWORKREDUCTIONPROJECT(3'ISO'104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAME1R.E.GinnaNuclearPowerPlantDOCKETNUMBER205000244YEAR94-00300LERHIISER6SEQUEHTIALREVISIOHPAGE33OF8TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A)(17)TheI&CtechnicianthennotifiedtheControlRoomoftheevent,andthathehadinstalledthemissingplug.TheControlRoomoperatorsreaffirmedtheI&Cforeman'sdecision.Theuninstalledplugwasa3/8inchswagelokplug,normallyinstalledontheinstrumentlineforPI-2223,"EquipmentHatchInnerVolume"I"ManifoldAirPressure".Thisinstrumentlinecontainsamanualvalve(V-8060,"InstrumentRootValvetoPI-2223<<).V-8060isdepictedonthe.pipingandinstrumentationdrawingasopen,andwasfoundopen.WithV-8060openandthepluguninstalled,therewasthepotentialforadirectpathfromCNMTtotheoutsideanytimetheEquipmentHatchInneraccessdoorwasopen.TheI&CforemanandtheControlRoomoperatorsformallydocumentedtheevent,andtheoperatornotifiedhighersupervisionandtheNuclearRegulatoryCommission(NRC)ResidentInspector.TheShiftSupervisorconfirmedthattheI&CtechnicianhadcheckedtheCNMTEquipmentHatchareaforadditionalmissingplugs.Asanadditionalprecaution,theShiftSupervisordirectedanAuxiliaryOperatortochecktheCNMTPersonnelHatchareaforanysimilarbreachesofCNMTintegrity.Nosimilarorpotentialbreacheswereidentified.Areviewofplantrecordswasimmediatelyperformed,toidentifywhentheswagelokplugshouldhavebeeninstalled,andwhentheCNMTEquipmentHatchInneraccessdoorwasopenwhiletheplugwasnotinstalled.ThisreviewconcludedthattheoneswagelokplugthatwasfounduninstalledintheEquipmentHatchareaisaddressedduringtheperformanceofsurveillanceprocedurePT-22.4,"EquipmentHatchBetweenDoorVolumeLeakRateTest".AspartofPT-22.4,twoplugsareremovedandsubsequentlyreinstalled.ThereviewofplantrecordsconcludedthatonNovember12,1993,oneoftheplugswasproperlyinstalledandtheotherwasnot,followingperformanceofPT-22.4.ThereviewalsoconcludedthattheCNMTEquipmentHatchInneraccessdoorwasopenedonNovember18,1993,withtheplantnotinColdShutdown.Atapproximately1630ESTonFebruary8,1994,itwasdeterminedthatthiseventwasreportableunder10CFR50.72(b)(2)(,iii)(C).TheNRCwassubsequentlynotifiedatapproximately1710EST.HRCFORM366A(592)

NRCFORM366A(5-92)U.S.NUCLEARREGULATORYCQIIISSION1LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBY(S(BNO3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIOHREQUEST:50.0HRS.FORWARDCOMMENTSREGARDIHGBURDENESTIMATETOTHEINFORMATIONANDRECORDSMAHAGEHENTBRANCH(MNBB7714),U.S.NUCLEARREGULATORYCOMMISSIOH,WASHINGTON,OC20555-0001,AHDTOTHEPAPERWORKREDUCTIONPROJECT(3150.0104),OFFICEOFMANAGEMEHTANDBUDGETWASHINGTONDC20503.FACILITYNAME1R.E.GinnaNuclearPowerPlantDOCKETHIMBER205000244YEAR94LERNNBER6SEQUEHTIALM-003--REVISIOH00PAGE34OF8TEXT(lfmorespaceisrequired,useadditionalcopiesofHRCForm366A)(17)C~INOPERABLESTRUCTURESICOMPONENTSiORSYSTEMSTHATCONTRIBUTEDTOTHEEVENT:Thecombinationoftheuninstalledplugandtheopenvalve(V-8060)createdadirectpathfromtheCNMTtotheoutside,resultinginalossofCNMTintegrity,whenevertheEquipmentHatchInneraccessdoorwasopen.ThisdoorwasopenedseveraltimesonNovember18,1993,duringaperiodofworkactivitiesintheCNMT.D.OTHERSYSTEMSORSECONDARYFUNCTIONSAFFECTED:NoneE.METHODOFDISCOVERY:ThiseventwasidentifiedbyanI&CtechnicianwhowasperformingcalibrationofEquipmentHatchpressuregauges.F.OPERATORACTION:TheControlRoomoperatorsreaffirmedtheI&Cforeman'sdecisiontoinstallthemissingplug.Subsequently,theControlRoomoperatorsnotifiedhighersupervisionandtheNRCResidentInspector.TheoperatorsalsodirectedthattheCNMTPersonnelHatchareabeinspectedforthepotentialofothermissingplugsthatcouldaffectCNMTintegrity.Afterreportabilitywasdetermined,theControlRoomoperatorsnotifiedtheNRCper10CFR50.72(b)(2),4HourNon-EmergencyNotification.G.SAFETYSYSTEMRESPONSES:NoneHRCFORM366A(5-92)

NRCFORM366A(5-92)U.s.HUGLEARREGULATDRYcQellssloNLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYONNO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYlllTHTHISINFORMATIONCOLLECTIONREDUEST:50.0HRS.FORNARDCOMMENTSREGARDINGBURDENESTIMATETOTHEINFORMATIONAHDRECORDSHANAGEMENTBRANCH(MNBB7714),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555-0001ANDTOTHEPAPERNORKREDUCTIONPROJECT(31i0-0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAME1R.E.GinnaNuclearPowerPlantDOCKETNWBER2YEAR0500024494--00300LERNIHIBER6SEQUENTIALREVISIONPACE35OF8TEXT(Ifmorespaceisrequired,useadditionalcopiesofHRCForm366A)(17)III.CAUSEOFEVENTA.IMMEDIATECAUSE:TheimmediatecauseofthelossofCNMTintegritywasanundetectedpotentialleakpathfromCNMTtothedutside.Thisleakpathexistedbecauseoneswagelokplugwasuninstalledonaninstrumentlinecontaininganopenmanualvalve.Thisleak'athonlyexistedwhentheCNMTEquipmentHatchInneraccessdoorwassimultaneouslyopen.B.INTERMEDIATECAUSE:ArecordsreviewconcludedthattheintermediatecauseoftheuninstalledplugintheEquipmentHatchareawasrelatedtosurveillancetestprocedurePT-22.4,lastperformedonNovember12,1993.AHumanPerformanceEnhancementSystem(HPES)evaluationwasconducted,andconfirmedthatoneofthe.plugswasnotproperlyreinstalledwhenPT-22.4wascompleted,atapproximately1600ESTonNovember12,1993.C.ROOTCAUSE:TheunderlyingcauseofthefailuretoproperlyreinstalltheswageloktubeplugintheEquipmentHatchareawasapersonnelerror.(ThiseventisNUREG-1022(A)causecode,PersonnelError.)Thiswasacognitivepersonnelerroronthepartofa'esultsandTest(R&T)technician,inthattheactionsoftheR&TtechnicianwerenotinaccordancewiththedirectionofprocedurePT-22.4.Therewerenounusualcharacteristicsoftheworklocation.HRCFORM366A(5-92)

NRCFORH366A(5-92)U.SNUCLEARREGULATORYCOHHISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBY(NBMO.3150-0104EXPIRES5/31/95ESTIHATEDBURDENPERRESPONSETOCOMPLYWITHTHISIHFORHATIOHCOLLECTIOHREOUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIHATETOTHEIHFORHATIONANDRECORDSHANAGEHENTBRANCH(MHBB7714),U.S.NUCLEARREGULATORYCOMMISSIONSWASHINGTON,DC20555-0001,ANDTOTHEPAPERWORKREDUCTIONPROJECT(3'150-0104),OFFICEOFMAMAGEMEHTANDBUDGETWASHINGTONDC20503.FACILITYNAME1R.E.GinnaNuclearPowerPlantDOCKETMNIBER2YEAR0500024494LERMIHIBER6)SEQUENTIAL--003REVISIGH00PAGE36OF8TENT(Ifmorespaceisrequired,useadditionalcopiesofHRCForm366A)(17)IV.ANALYSISOFEVENTThiseventisreportableinaccordancewith10CFR50.73,LicenseeEventReportSystem,items(a)(2)(i)(B)and(a)(2)(v),whichrequireareportof,"Anyoperationorconditionprohibited,bytheplant'sTechnicalSpecifications",and"Anyeventor'onditionthatalonecouldhavepreventedthefulfillmentofthesafetyfunctionofstructuresorsystemsthatareneededtocontrolthereleaseofradioactivematerialormitigatetheconsequencesofanaccident".ThepotentialforaleakpathwascreatedonNovember12,1993,andalossofCNMTintegrityexistedforshortperiodsoftimeonNovember18,1993.LossofCNMTintegrity,priortotheplantbeinginthecoldshutdowncondition,isaviolationofTechnicalSpecification(TS)3.6.1.a.ThetubingforPI-2223connectstotheEquipmentHatchassemblybetweentheInnerandOuteraccessdoors.PI-2223isusedduringperformanceofapressurizationtestbetweenthetwodoors,asrequiredbyTS4.4.2.4.c.ProcedurePT-22.4accomplishesthistest.Eachaccessdoorissuppliedwithtwoseparateseals,suchthateitherdoorcanprovidethenecessaryCNMTboundary,.BothdoorsarenormallylockedclosedwhenCNMTintegrityisrequired,andonlyonedoorcanbeopenedatatime.Therefore,theCNMTleakpathcanonlyexistwhentheEquipmentHatchInneraccessdoorisopen.TheconditionstocreatethisleakpathexistedsinceNovember12,1993,buttheactualleakpathconditiononlyexistedonNovember18,1993,duringtimeswhentheEquipmentHatchInneraccessdoorwasopen.NRCFORH366A(5-92)

NRCFORM366A(5.92)US.NUCLEARREGULATORYCOltIISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYOMBNO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIOHREQUEST:50'HRS.FORWARDCOMMEHTSREGARDIHGBURDENESTIMATETOTHEINFORMATIONAHDRECORDSMANAGEMENTBRANCH(MHBB7714),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTOH,DC20555-0001AHDTOTHEPAPERWORKREDUCTIOHPROJECT(31400104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAME1R.E.GinnaNuclearPowerPlantDOCKETNUMBER205000244YEARLERNUMBER6SEQUENTIAL94--003REVISION00PAGE37OF8TEXT(Ifmorespaceisrequired,useadditionatcopiesofNRCForm366A)(17)Anassessmentwasperformedconsideringboththesafetyconsequencesandimplicationsofthisevent.TheresultsofthisassessmentarethattherewerenooperationalorsafetyconsequencesorimplicationsattributedtothelossofCNMTintegritybecause:TheconditiononlyexistedforshortperiodsoftimeonNovember18,1993.Atthistime,theplantwasattheHotShutdownconditionandboratedtotheColdShutdownBoronconcentration,inpreparationforrepairinganon-radioactivesteamleakinsideCNMT.~Undertheseconditions,theconsequencesofanyradiologicalaccidentarelesssevere.~TheEquipmentHatchInneraccessdoor,byitself,providesasufficientCNMTboundarywhenclosed.Thisdoorismaintainedclosedduringnormalplantoperation.WiththeplantatHotShutdownonNovember18,1993,theInner.accessdoorwasopenedatapproximately0457EST,andwassubsequentlyopenedseveraltimesonthatdate.SecuritypersonnelmaintainedamanuallogoftheuseofthisCNMTaccesspoint,asthereisnoautomaticindicationofInneraccessdoorposition.AvailablelogsandotherrecordswereusedtoattempttoquantifythelengthoftimetheInneraccessdoorwasopen,asworkersweremovingmaterialsinandoutofCNMT.Noaccurateestimatecouldbemade.TheplantwasbroughttotheColdShutdownconditionatapproximately2200ESTonNovember18,1993.InColdShutdown,TS3.6.1.adoesnotapply.Therefore,evenwiththeplugmissing,thevalveopen,andtheInneraccessdooropen,nofurtherviolationsofTS3.6.1.acouldoccur.TheplantleftColdShutdownonNovember20,1993,atapproximately1235EST.TheEquipmentHatchInneraccessdoorwasnotopenedafterthattime.Thus,noleakpathwhichwouldresultinalossofCNMTintegrityexistedafterthatdate.Also,noeventoccurredduringthetimethattheEquipmentHatchInneraccessdoorwasopenwhichwouldresultinaradioactiverelease.Basedontheabove,itcanbeconcludedthatthepublic'shealthandsafetywasassuredatalltimes.NRCFORM366A(5-92)

NRCFORM366A(5-92)US.NUCLEARREGULATORYCQIIISSIDNLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYMBNO.3150-0104EXPIRES5/31/95ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHEINFORMATIONANDRECORDSMANAGEMEHTBRANCH(MHBB7714),U.STNUCLEARREGULATORYCOMMISSIOH,WASHINGTOH,DC20555-0001AHDTOTHEPAPERWORKREDUCTIONPROJECT(31/0-0104),OFFICEOFMANAGEMENTANDBUDGETWASHINGTONDC20503.FACILITYNAME1R.E.GinnaNuclearPowerPlantDOCKETNUMBER205000244LERNUMBER6YEARSEQUENTIAL94--003REVISIONM00PAGE38OF8TEXT(lfmorespaceisrequired,useadditionalcopiesofHRCForm366A)(17)V.CORRECTIVEACTIONA.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENTNORMALSTATUS:~TheI&Ctechnician,underthedirectionofh5.sforeman,installedtheswagelokplugontheopentubeendintheEquipmentHatcharea.B.ACTIONTAKEN,ORPLANNEDTOPREVENTRECURRENCE:Managementtookappropriatedisciplinaryactionfortheindividualinvolved.Proceduresanddrawingswillbechangedtomaintainvalve8060normallyclosed.SurveillancetestproceduresfortheEquipmentHatchbetweendoorvolumeandPersonnelHatchbetweendoorvolumewillbeenhancedtoclearlycontrolremovalandreinstallationoftheswagelokplugs;Administrativecontrolswillbeappliedtothetubing/instrumentationconfiguration,forboththeCNMTEquipmentHatchareaandtheCNMTPersonnelHatcharea,asaCNMTpenetration/boundary.VI.ADDITIONALINFORMATIONA.FAILEDCOMPONENTS:NoneB.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistoricalsearchwasconductedwiththefollowingresults:NodocumentationofsimilarLEReventswiththesamerootcauseatGinnaNuclearPowerPlantcouldbeidentified.CSPECIALCOMMENTS:NoneHRCFORM366A(5-92)