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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17241A4891999-10-0707 October 1999
LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr
ML17241A4111999-07-16016 July 1999
LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr
ML17241A4031999-07-0606 July 1999
LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr
ML17241A4041999-07-0606 July 1999
LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr
ML17241A3941999-06-30030 June 1999
LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr
ML17241A3551999-06-0404 June 1999
LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr
ML17241A3321999-05-17017 May 1999
LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11
ML17241A3271999-05-0606 May 1999
LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr
ML17229B0791999-04-0707 April 1999
LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr
ML17229B0801999-04-0707 April 1999
LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr
ML17229B0541999-03-10010 March 1999
LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr
ML17229A9901999-01-20020 January 1999
LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr
ML17229A9821999-01-0404 January 1999
LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr
ML17229A9611998-12-22022 December 1998
LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr
ML17229A9561998-12-15015 December 1998
LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr
ML17229A9301998-11-25025 November 1998
LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage
ML17229A9021998-11-0404 November 1998
LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr
ML17229A8771998-10-14014 October 1998
LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr
ML17229A8761998-10-14014 October 1998
LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr
ML17229A8511998-09-0202 September 1998
LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr
ML17229A8201998-07-29029 July 1998
LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr
ML17229A7411998-05-28028 May 1998
LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr
ML17229A7381998-05-21021 May 1998
LER 98-006-00:on 980421,missed EDG Fuel Oil Sample Surveillance Was Noted.Caused by Personnel Error.Revised Fuel Oil Sampling Service Purchase Order & Revised Site procedure.W/980521 Ltr
ML17229A7011998-04-27027 April 1998
LER 98-003-00:on 980326,discovered Containment Pressure Instrumentation Design Single Failure Vulnerability.Caused by Inadequate Design by Personnel Error.Removed RPS & ESFAS Containment Pressure Bypass Keys immediately.W/980427 Ltr
ML17229A6761998-04-0202 April 1998
LER 98-005-00:on 980305,identified Two Conditions That Were Outside App R Design Bases.Caused by Design Oversight During Development of Original App R Safe SD Design.Established 30 Minute Roving Fire Watches & Provided training.W/980402 Ltr
ML17229A6731998-03-26026 March 1998
LER 98-002-00:on 980224,radiation Monitor Surveillance Inadequacies Led to Operating of Facility Prohibited by Tss. Caused by Congnitive Personnel Error.Permanent Procedure Changes Were implemented.W/980326 Ltr
ML17229A6551998-03-0505 March 1998
LER 98-001-00:on 980206,high/low Pressure Shutdown Cooling Interface Was Noted Outside App R Design Bases.Caused by Personnel Error.Addl Guidance Was Provided to Engineering Dept personnel.W/980305 Ltr
ML17229A6281998-02-19019 February 1998
LER 98-004-00:on 980121,emergency Lighting Outside App R Design Bases Occurred.Caused by Congnitive Personnel Error During Translation of App R Section Iii.Procedures Onop 1 & 2 ONP-100.01 Were Issued for Use on 980206.W/980219 Ltr
ML17229A6211998-02-0909 February 1998
LER 98-003-00:on 980110,manual Rt Due to DEH Leak at Turbine Test Block Was Noted.Caused by o-ring Extrusion.Shortened Bolts by About 0.125 & Reinstalled at Correct Torque values.W/980209 Ltr
ML17229A6191998-02-0404 February 1998
LER 98-002-00:on 980105,CIS Bistable in Bypass Resulted in Condition Prohibited by Tss.Caused by Personnel Error. Radiation Monitor Was Restored to service.W/980204 Ltr
ML17229A6161998-02-0303 February 1998
LER 98-001-00:on 980104,inadvertent RPS Actuation Occurred Due to Personnel Error.Caused by Procedural Inadequacies & Inadequate self-checking by Licensed Utility Personnel. Placards Have Been Placed in CRs.W/980203 Ltr
ML17229A6051998-01-27027 January 1998
LER 97-010-01:on 971027,inadvertent Core Alteration Prohibited by TSs Were Noted Due to Stuck Cea.Caused by Personnel Error.Cea #24 Was Dislodged & Transferred to Spent Pool for insp.W/980127 Ltr
ML17229A5501997-12-0505 December 1997
LER 97-008-00:on 971107,inadequate CR Ventilation Surveillance Resulted in Condition Prohibited by Ts.Caused by non-cognitive Personnel Error.Operating Procedure 2-1900050 Was revised.W/971205 Ltr
ML17309A9091997-12-0202 December 1997
LER 97-011-00:on 971102,non-conservative RAS Set Point Resulted in Operation Prohibited by Ts.Caused by Inadequate Set Point & Instrument Loop Scaling Process.Revised ESFAS Functional Tp W/Proper Set point.W/971202 Ltr
ML17229A5391997-11-26026 November 1997
LER 97-010-00:on 971027,inadvertant Core Alteration Prohibited by TS Occurred.Caused by CEA Failure to Detach from Ugs.Safety Evaluation Was Performed & Procedural Rev Made to Continue Upper Guide Structure move.W/971126 Ltr
ML17229A5151997-11-0707 November 1997
LER 97-007-00:on 971008,inoperable Containment Cooling Fan Resulted in Operation of Facility Outside Design Basis. Caused by non-cognitive Personnel Error.Ccs Operation Was Revised & Issued on 971013.W/971107 Ltr
ML17229A4991997-10-17017 October 1997
LER 97-009-00:on 970917,inoperable PORV Block Valve Resulted in Operation Prohibited by Tech Specs Occurred.Caused by Plant GL 89-10 Program Plan to Review Plant Manager Action Item Sys.Porv Block Valve V-1403 restored.W/971017 Ltr
ML17309A9011997-08-27027 August 1997
LER 97-008-00:on 970728,mechanical Fire Penetrations Were Inoperable & Outside App R Design Bases.Caused by Seal Mfg Not Providing Formal Documentation for Installed Seals. Modified Inoperable Fire penetrations.W/970827 Ltr
ML17229A4311997-07-29029 July 1997
LER 97-006-00:on 970630,discovered Inadequate Testing of Engineered Safety Features Subgroup Relays.Caused by Inadequacy in Implementing TS Requirements in Surveillance Procedures.Revised Surveillance procedures.W/970729 Ltr
ML17229A4241997-07-25025 July 1997
LER 97-005-00:on 970625,discovered That Hot Shutdown Control Panel Shutdown Cooling Flow indicator,FI-3306 Inoperable. Caused by Weakness in Work Order & Procedure Used to Repair FI-3306.Section Meeting W/I&C Planners held.W/970725 Ltr
ML17229A3971997-07-11011 July 1997
LER 97-004-00:on 970611,discovered Incorrect Original Cable Tray Fire Stop Assembly Installation Was Outside App R Design Basis.Caused by Personnel Error.Hourly Fire Watch Patrols Will Be posted.W/970711 Ltr
ML17229A3871997-06-19019 June 1997
LER 97-003-00:on 970521,determined Required Post Maint Open Stroke Test for Valve V3245,2B2 SIT Discharge Check Valve, Had Not Been Performed.Caused by Personnel Error.Procedure revised.W/970619 Ltr
ML17229A3841997-06-17017 June 1997
LER 97-002-00:on 970518,containment Sump Debris Screen Was Not IAW Design Due to Gaps in Screen Encl.Performed SER to Document Containment Sump Design requirements.W/970617 Ltr
ML17229A3751997-06-0202 June 1997
LER 97-006-00:on 970501,operation Was Prohibited by TS Due to Inadequately Tested Degraded Voltage Sys.Revised Unit 1 ESFAS Surveillance Test procedure.W/970602 Ltr
ML17229A3611997-05-29029 May 1997
LER 97-007-00:on 970502,reactor Coolant Pump Oil Collection Sys Was Outside App R Design Bases.Identified Leak Sites Were Repaired & Mods to RCP Oil Collection Sys to Capture Any Future Leakage from areas.W/970529 Ltr
ML17229A3491997-05-21021 May 1997
LER 97-001-00:on 970423,containment Isolation Actuation Occurred.Caused by Increased Radiation Levels During Removal of Upper Guide Structure.Proper Actuation of Containment Isolation Components Was verified.W/970521 Ltr
ML17229A3441997-05-13013 May 1997
LER 97-005-00:on 970419,reactor Was Shutdown Due to Reactor Coolant Pressure Boundary Leakage.Hot Cracking Was Caused by Weld Contamination.Repairs to RCPB Were Completed & 1A SDC Train Was Restored to Svc
ML17229A3141997-04-30030 April 1997
LER 97-004-00:on 970402,refueling Machine Was Operating in Manner Prohibited by TS Due to Original Design of Refueling Machine Bypass Feature Conflicting W/Ts Requirements. Eliminated Overload Cut Off Limit bypass.W/970430 Ltr
ML17229A2951997-03-31031 March 1997
LER 97-003-00:on 970304,automatic Rt Resulted from Loss of Electrical Power to 1A2 Rc Pump.Rcp Breaker Was Replaced & Pump Was Returned to svc.W/970331 Ltr
ML17229A2721997-03-21021 March 1997
LER 97-002-00:on 970221,operation in Excess of Max Rated Thermal Power Occurred Due to Digital Data Processing Sys (Ddps) Calorimetric Error.Verified Acceptable Performance of Ddps Functions & Reviewed Software mods.W/970321 Ltr
1999-07-06
[Table view]
Category:RO)
MONTHYEARML17241A4891999-10-0707 October 1999
LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr
ML17241A4111999-07-16016 July 1999
LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr
ML17241A4031999-07-0606 July 1999
LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr
ML17241A4041999-07-0606 July 1999
LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr
ML17241A3941999-06-30030 June 1999
LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr
ML17241A3551999-06-0404 June 1999
LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr
ML17241A3321999-05-17017 May 1999
LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11
ML17241A3271999-05-0606 May 1999
LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr
ML17229B0791999-04-0707 April 1999
LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr
ML17229B0801999-04-0707 April 1999
LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr
ML17229B0541999-03-10010 March 1999
LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr
ML17229A9901999-01-20020 January 1999
LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr
ML17229A9821999-01-0404 January 1999
LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr
ML17229A9611998-12-22022 December 1998
LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr
ML17229A9561998-12-15015 December 1998
LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr
ML17229A9301998-11-25025 November 1998
LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage
ML17229A9021998-11-0404 November 1998
LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr
ML17229A8771998-10-14014 October 1998
LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr
ML17229A8761998-10-14014 October 1998
LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr
ML17229A8511998-09-0202 September 1998
LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr
ML17229A8201998-07-29029 July 1998
LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr
ML17229A7411998-05-28028 May 1998
LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr
ML17229A7381998-05-21021 May 1998
LER 98-006-00:on 980421,missed EDG Fuel Oil Sample Surveillance Was Noted.Caused by Personnel Error.Revised Fuel Oil Sampling Service Purchase Order & Revised Site procedure.W/980521 Ltr
ML17229A7011998-04-27027 April 1998
LER 98-003-00:on 980326,discovered Containment Pressure Instrumentation Design Single Failure Vulnerability.Caused by Inadequate Design by Personnel Error.Removed RPS & ESFAS Containment Pressure Bypass Keys immediately.W/980427 Ltr
ML17229A6761998-04-0202 April 1998
LER 98-005-00:on 980305,identified Two Conditions That Were Outside App R Design Bases.Caused by Design Oversight During Development of Original App R Safe SD Design.Established 30 Minute Roving Fire Watches & Provided training.W/980402 Ltr
ML17229A6731998-03-26026 March 1998
LER 98-002-00:on 980224,radiation Monitor Surveillance Inadequacies Led to Operating of Facility Prohibited by Tss. Caused by Congnitive Personnel Error.Permanent Procedure Changes Were implemented.W/980326 Ltr
ML17229A6551998-03-0505 March 1998
LER 98-001-00:on 980206,high/low Pressure Shutdown Cooling Interface Was Noted Outside App R Design Bases.Caused by Personnel Error.Addl Guidance Was Provided to Engineering Dept personnel.W/980305 Ltr
ML17229A6281998-02-19019 February 1998
LER 98-004-00:on 980121,emergency Lighting Outside App R Design Bases Occurred.Caused by Congnitive Personnel Error During Translation of App R Section Iii.Procedures Onop 1 & 2 ONP-100.01 Were Issued for Use on 980206.W/980219 Ltr
ML17229A6211998-02-0909 February 1998
LER 98-003-00:on 980110,manual Rt Due to DEH Leak at Turbine Test Block Was Noted.Caused by o-ring Extrusion.Shortened Bolts by About 0.125 & Reinstalled at Correct Torque values.W/980209 Ltr
ML17229A6191998-02-0404 February 1998
LER 98-002-00:on 980105,CIS Bistable in Bypass Resulted in Condition Prohibited by Tss.Caused by Personnel Error. Radiation Monitor Was Restored to service.W/980204 Ltr
ML17229A6161998-02-0303 February 1998
LER 98-001-00:on 980104,inadvertent RPS Actuation Occurred Due to Personnel Error.Caused by Procedural Inadequacies & Inadequate self-checking by Licensed Utility Personnel. Placards Have Been Placed in CRs.W/980203 Ltr
ML17229A6051998-01-27027 January 1998
LER 97-010-01:on 971027,inadvertent Core Alteration Prohibited by TSs Were Noted Due to Stuck Cea.Caused by Personnel Error.Cea #24 Was Dislodged & Transferred to Spent Pool for insp.W/980127 Ltr
ML17229A5501997-12-0505 December 1997
LER 97-008-00:on 971107,inadequate CR Ventilation Surveillance Resulted in Condition Prohibited by Ts.Caused by non-cognitive Personnel Error.Operating Procedure 2-1900050 Was revised.W/971205 Ltr
ML17309A9091997-12-0202 December 1997
LER 97-011-00:on 971102,non-conservative RAS Set Point Resulted in Operation Prohibited by Ts.Caused by Inadequate Set Point & Instrument Loop Scaling Process.Revised ESFAS Functional Tp W/Proper Set point.W/971202 Ltr
ML17229A5391997-11-26026 November 1997
LER 97-010-00:on 971027,inadvertant Core Alteration Prohibited by TS Occurred.Caused by CEA Failure to Detach from Ugs.Safety Evaluation Was Performed & Procedural Rev Made to Continue Upper Guide Structure move.W/971126 Ltr
ML17229A5151997-11-0707 November 1997
LER 97-007-00:on 971008,inoperable Containment Cooling Fan Resulted in Operation of Facility Outside Design Basis. Caused by non-cognitive Personnel Error.Ccs Operation Was Revised & Issued on 971013.W/971107 Ltr
ML17229A4991997-10-17017 October 1997
LER 97-009-00:on 970917,inoperable PORV Block Valve Resulted in Operation Prohibited by Tech Specs Occurred.Caused by Plant GL 89-10 Program Plan to Review Plant Manager Action Item Sys.Porv Block Valve V-1403 restored.W/971017 Ltr
ML17309A9011997-08-27027 August 1997
LER 97-008-00:on 970728,mechanical Fire Penetrations Were Inoperable & Outside App R Design Bases.Caused by Seal Mfg Not Providing Formal Documentation for Installed Seals. Modified Inoperable Fire penetrations.W/970827 Ltr
ML17229A4311997-07-29029 July 1997
LER 97-006-00:on 970630,discovered Inadequate Testing of Engineered Safety Features Subgroup Relays.Caused by Inadequacy in Implementing TS Requirements in Surveillance Procedures.Revised Surveillance procedures.W/970729 Ltr
ML17229A4241997-07-25025 July 1997
LER 97-005-00:on 970625,discovered That Hot Shutdown Control Panel Shutdown Cooling Flow indicator,FI-3306 Inoperable. Caused by Weakness in Work Order & Procedure Used to Repair FI-3306.Section Meeting W/I&C Planners held.W/970725 Ltr
ML17229A3971997-07-11011 July 1997
LER 97-004-00:on 970611,discovered Incorrect Original Cable Tray Fire Stop Assembly Installation Was Outside App R Design Basis.Caused by Personnel Error.Hourly Fire Watch Patrols Will Be posted.W/970711 Ltr
ML17229A3871997-06-19019 June 1997
LER 97-003-00:on 970521,determined Required Post Maint Open Stroke Test for Valve V3245,2B2 SIT Discharge Check Valve, Had Not Been Performed.Caused by Personnel Error.Procedure revised.W/970619 Ltr
ML17229A3841997-06-17017 June 1997
LER 97-002-00:on 970518,containment Sump Debris Screen Was Not IAW Design Due to Gaps in Screen Encl.Performed SER to Document Containment Sump Design requirements.W/970617 Ltr
ML17229A3751997-06-0202 June 1997
LER 97-006-00:on 970501,operation Was Prohibited by TS Due to Inadequately Tested Degraded Voltage Sys.Revised Unit 1 ESFAS Surveillance Test procedure.W/970602 Ltr
ML17229A3611997-05-29029 May 1997
LER 97-007-00:on 970502,reactor Coolant Pump Oil Collection Sys Was Outside App R Design Bases.Identified Leak Sites Were Repaired & Mods to RCP Oil Collection Sys to Capture Any Future Leakage from areas.W/970529 Ltr
ML17229A3491997-05-21021 May 1997
LER 97-001-00:on 970423,containment Isolation Actuation Occurred.Caused by Increased Radiation Levels During Removal of Upper Guide Structure.Proper Actuation of Containment Isolation Components Was verified.W/970521 Ltr
ML17229A3441997-05-13013 May 1997
LER 97-005-00:on 970419,reactor Was Shutdown Due to Reactor Coolant Pressure Boundary Leakage.Hot Cracking Was Caused by Weld Contamination.Repairs to RCPB Were Completed & 1A SDC Train Was Restored to Svc
ML17229A3141997-04-30030 April 1997
LER 97-004-00:on 970402,refueling Machine Was Operating in Manner Prohibited by TS Due to Original Design of Refueling Machine Bypass Feature Conflicting W/Ts Requirements. Eliminated Overload Cut Off Limit bypass.W/970430 Ltr
ML17229A2951997-03-31031 March 1997
LER 97-003-00:on 970304,automatic Rt Resulted from Loss of Electrical Power to 1A2 Rc Pump.Rcp Breaker Was Replaced & Pump Was Returned to svc.W/970331 Ltr
ML17229A2721997-03-21021 March 1997
LER 97-002-00:on 970221,operation in Excess of Max Rated Thermal Power Occurred Due to Digital Data Processing Sys (Ddps) Calorimetric Error.Verified Acceptable Performance of Ddps Functions & Reviewed Software mods.W/970321 Ltr
1999-07-06
[Table view]
Category:TEXT-SAFETY REPORT
MONTHYEARML17241A4891999-10-0707 October 1999
LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr
ML17241A4951999-09-30030 September 1999
Monthly Operating Repts for Sept 1999 for St Lucie,Units 1 & 2.With 991014 Ltr
ML17241A4741999-08-31031 August 1999
Rev 1 to PCM 99016, St Lucie Unit 1,Cycle 16 Colr.
ML17241A4591999-08-31031 August 1999
Monthly Operating Repts for Aug 1999 for St Lucie,Units 1 & 2.With 990913 Ltr
ML17241A4301999-07-31031 July 1999
Monthly Operating Repts for Jul 1999 for St Lucie Units 1 & 2.With 990805 Ltr
ML17241A4111999-07-16016 July 1999
LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr
ML17241A4031999-07-0606 July 1999
LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr
ML17241A4041999-07-0606 July 1999
LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr
ML17241A4091999-06-30030 June 1999
Monthly Operating Repts for June 1999 for St Lucie,Units 1 & 2.With 990712 Ltr
ML17241A3941999-06-30030 June 1999
LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr
ML17355A3681999-06-30030 June 1999
Revised Update to Topical QA Rept, Dtd June 1999
ML17241A3551999-06-0404 June 1999
LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr
ML17241A3631999-05-31031 May 1999
Monthly Operating Repts for May 1999 for St Lucie Units 1 & 2.With 990610 Ltr
ML17241A3321999-05-17017 May 1999
LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11
ML17241A3271999-05-0606 May 1999
LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr
ML17241A3331999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for St Lucie,Units 1 & 2.With 990517 Ltr
ML17229B0801999-04-0707 April 1999
LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr
ML17229B0841999-04-0707 April 1999
Rev 2 to PSL-ENG-SEMS-98-102, Engineering Evaluation of ECCS Suction Lines.
ML17229B0791999-04-0707 April 1999
LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr
ML17229B0961999-03-31031 March 1999
Monthly Operating Repts for Mar 1999 for St Lucie,Units 1 & 2.With 990408 Ltr
ML17229B0541999-03-10010 March 1999
LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr
ML17229B0461999-02-28028 February 1999
Monthly Operating Repts for Feb 1999 for St Lucie,Units 1 & 2.With 990310 Ltr
ML17229B0051999-01-31031 January 1999
Monthly Operating Repts for Jan 1999 for St Lucie,Units 1 & 2.With 990211 Ltr
ML17229A9901999-01-20020 January 1999
LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr
ML17229A9961999-01-14014 January 1999
SG Tube Inservice Insp Special Rept.
ML17229A9821999-01-0404 January 1999
LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr
ML17229A9831998-12-31031 December 1998
Monthly Operating Repts for Dec 1998 for St Lucie,Units 1 & 2.With 990111 Ltr
ML17229A9611998-12-22022 December 1998
LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr
ML17229A9561998-12-15015 December 1998
LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr
ML17241A3581998-12-0909 December 1998
Changes,Tests & Experiments Made as Allowed by 10CFR50.59 for Period of 970526-981209.
ML17229A9421998-11-30030 November 1998
Monthly Operating Repts for Nov 1998 for St Lucie,Units 1 & 2.With 981215 Ltr
ML17229A9301998-11-25025 November 1998
LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage
ML17229A9021998-11-0404 November 1998
LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr
ML17241A4931998-11-0101 November 1998
Statement of Account for Period of 981101-990930 for Suntrust Bank,As Trustee for Florida Municipal Power Agency Nuclear Decommissioning Trust (St Lucie Project).
ML17229A9051998-10-31031 October 1998
Monthly Operating Repts for Oct 1998 for St Lucie,Units 1 & 2.With 981110 Ltr
ML17229A8871998-10-19019 October 1998
Part 21 Rept Re Potential Defect in Swagelok Stainless Steel Front Ferrule,Part Number SS-503-1 Which Was Machined with Improper Length.C/A Includes Insp Equipment That Will 100% Identify Short Length
ML17229A8781998-10-19019 October 1998
Part 21 Rept Re Potential Defect in Swagelok Stainless Steel Front Ferrule,Part Number SS-503-1,which Was Machined with Improper Length.Insp Equipment That Will 100% Identify Short Length
ML17229A8771998-10-14014 October 1998
LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr
ML17229A8761998-10-14014 October 1998
LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr
ML17229A8721998-09-30030 September 1998
Monthly Operating Repts for Sept 1998 for St Lucie Units 1 & 2.With 981009 Ltr
ML17229A8511998-09-0202 September 1998
LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr
ML17229A8611998-08-31031 August 1998
Monthly Operating Repts for Aug 1998 for St Lucie,Units 1 & 2.With 980911 Ltr
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
ML17229A8481998-08-0707 August 1998
Rev 1 to PSL-ENG-SEFJ-98-013, St Lucie Unit 2,Cycle 10 Colr.
ML17229A9461998-08-0707 August 1998
Rev 0 to PCM 98016, St Lucie Unit 2,Cycle 11 Colr.
ML17229A8301998-07-31031 July 1998
Monthly Operating Repts for July 1998 for St Lucie,Units 1 & 2.W/980814 Ltr
ML17229A8201998-07-29029 July 1998
LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr
ML17229A7981998-06-30030 June 1998
Monthly Operating Repts for June 1998 for St Lucie,Units 1 & 2.W/980713 Ltr
ML17229A7701998-05-31031 May 1998
Monthly Operating Repts for May 1998 for St Lucie,Units 1 & 2.W/980612 Ltr
ML17229A7411998-05-28028 May 1998
LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr
1999-09-30
[Table view] |
Text
CATEGORY1REGULATOINFORMATION DISTRIBUTION STEM(RIDS)ACCESSION'NBR:9907210143 DOC.DATE:
99/07/16NOTARIZED:
NOFACIL:50-389 St.LuciePlant,Unit2,FloridaPower&LightCo.AUTH.NAMEAUTHORAFFILIATION FREHAFER,K.W.
FloridaPowerSLightCo.STALL,J.A.
FloridaPower6LightCo.RECIP.NAME RECIPIENT AFFILIATION DOCKETI05000389
SUBJECT:
LER99-007-00:on 990610,cooldown transient duringreactorstartupwasnoted.Causedbypersonnel error.Trained6briefedpersonnel
&.revisedprocedures.
With990716ltr.DI'STRIBUTION CODE:IE22TCOPIESRECEIVED:LTR ENCLSIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:RECIPIENT IDCODE/NAME LPD2-2PDINTERNAL:
ACRSNRR/DIPM/IOLB NRR/DSSA/SPLB RES/DRAA/OERAB EXTERNAL:
LSTLOBBYWARDNOACPOORE,W.NRCPDRCOPIESLTTRENCL11RECIPIENT IDCODE/NAME GLEAVES,W 1CWzzz,.E, CENTER1NRR/DRIP/REXB 1RES/DET/ERAB 1RGN2,FILE0111LMITCOMARSHALL11NOACQUEENER,DS 11NUDOCSFULLTXTCOPIESLTTRENCL11111-11111111111DNNOTETOALL"RIDS"RECIPIENTS:
PLEASEHELPUSTOREDUCEWASTE.TOHAVEYOURNAMEORORGANIZATION REMOVEDFROMDISTRIBUTION LISTSORREDUCETHENUMBEROFCOPIESRECEIVEDBYYOUORYOURORGANIZATION, CONTACTTHEDOCUMENTCONTROLDESK(DCD)ONEXTENSION 415-2083NFULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:
LTTR16ENCL16 FioridaPower5LightCompany,6351S.OceanDrive,JensenBeach,FL34957'July16,1999L-99-16010CFR$50.4U.S.NuclearRegulatory Commission Attn:DocumentControlDeskWashington, D.C.20555Re:St.LucieUnit2DocketNo.50-389Reportable Event:1999-007-00 DateofEvent:June10,1999Personnel ErrorDuringReactorStartuLedtoUnlannedCooldownTransient Theattachedvoluntary LicenseeEventReport1999-007isbeingsubmitted toprovidenotification ofthesubjectevent.Verytrulyyours,J.A.Stall,'VicePresident St.LucieNuclearPlantJAS/EJW/KWF Attachment cc:RegionalAdministrator, USNRC,RegionHSeniorResidentInspector, USNRC,St.LucieNuclearPlant9'rr072iOX4G 9'rr07i6PDRADQCK05000389SPDRanFPLGroupcompany RCFORM366(8-1998)LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/characters foreachblock)Estimated burdenperresponsotocomplywiththismandatory information collection request:50hrs.Reportedlessonslearnedareincorporated jntothelicensing processandfedbacktoIndustry.
Forvrardcommentsregarding burdenestimatetotheRecordsManagement Branch(T-6F33),U.S.NuclearRegulatory Commission, Washington, DC20555~01, andtothePaperwork Reduction Proiect(3t5th0104),
OfficeofManagement andBudget,Washington, DC20503.Ifaninformation collection doesnotdisplayacurrently validOMBcontrolnumber,theNRCmaynotconductorsponsor,andapersonisnotrequiredtorespondto,theinformation collection.
U.S.NUCREGULATORY COMMISSION APPROVEDBYNO.3150-0104 EXPIRES06/30/2001 FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)05000389PAGE(3)Page1of5TITLE(4)Personnel ErrorDuringReactorStartupLedtoUnplanned CooldownTransient MONTH06DAYYEAR101999EVENTDATE(5)LERNUMBER(6)SEQUENTIAL REVISIONNUMBERNUMBER1999-007-00REPORTDATE(7)MONTHDAYYEAR07161999FACIUTYNAh'IEFACIUTYNAMEOTHERFACILITIES INVOLVED(8)DOCKETNuhIBERDOCKETNUMBEROPERATING MODE(9)20.2201(b)20.2203(a)(2)
(v)60.73(a)(2)(i)60.73(a)(2)
(viii)THISREPORTISSUBMITTED PURSUANTTOTHEREQUIREMENTS OF10CFRgt(Checkoneormoro)(11)POWERLEVEL(10)00020.2203(a)(1) 20.2203(a)
(2)(i)20.2203(a)(2)
(ii)20.2203(a)(2)(iii)20.2203(a)(2)(iv) 20.2203(a)
(3)(i)20.2203(a)(3)(ii)20.2203(a)(4) 50.36(c)(1) 60.36(c)(2) 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(o)(2)(x)73.71OTHERSpecifyInAbstractbeloworinNRCForm380ANAMELICENSEECONTACTFORTHISLER12)TELEPHONE NUMBEIt(IncludeAresCode)KennethW.Erehafer, Licensing Engineer(561)467-7748COMPLETEONELINEFOREACHCOMPONENT FAILUREDESCRIBED INTHISREPORT13CAusESYSTEMCOMPONENT MANUFACTURER REPORTABLE ToEPIXCAUSESYSTEMCOMPONENT MANUFACTURER REPORTABLE ToEPIXSUPPLEMENTAL REPORTEXPECTED(14)YES(Ifyee,completeEXPECTEDSUBMISSION DATE).XNOEXPECTEDSUBMISSION DATE(16)MONTHDAYABSTRACT(Limitto1400spaces,i.e.,approximate/y 15sing/ewpaced typewritten
/ines/(16)Thisvoluntary LERdescribes anunplanned reactorplant:cooldowntransient thatoccurredonJune10,1999.At0345hoursonJune10,1999,Unit"2wasinMode3atnormaloperating pressureandnormaloperating temperature.
Areactorstartupwasinprogress, buttemporarily suspended totroubleshootannunciator problems.
Licensedcontrolroompersonnel decidedtoperformpostmaintenance testingonthenumber3'throttle valve;anevolution thatrequiredlatchingtheturbine.At0412hours,theturbinewaslatchedwithoutincident.
Atapproximately 0420hours,thecontrolroomwasinformedthatthetestingwascompleteandthattheturbinecouldbetripped.Aftertheturbinewaslocallytripped,themainfeedwater 15percentbypassvalveswerechecked,buterroneously notreset,becausethecontroller outputhadnotchanged.At0423hours,severalannunciators cameinwhichindicated asteamgenerator overfeedcondition including letdownlowpressure, steamgenerator highlevels,andpressurizer lowlevel.Atthattime,the15percentvalveswerereset,theoverfeedwasterminated, andlevelswererestoredtonormalconditions.
Thiseventwascausedbythefailuretouseexistingprocedural guidanceonturbineshutdown.
Contributing factorsincludenon-conservative reactivity management decisions, inadequate operatorknowledge ontheoperation ofthemainfeedwater 15percentbypassvalves,andaninadequate pre-evolution brief.Corrective actionsincludetraining, briefings, andprocedure changes.NRCFORM360I0.1998)
RCFORM366A(6-I996)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)05000389LERNUMBER(6)YEARSEQUENTIAL REVISIONNUMBERNUMBER1999-007-00PAGE(3)Page2of5TEXT(Ifmorespeceisrequired, useeddidonel copiesof/VRCForm366A)(17]Description oftheEventAt0345hoursonJune10,1999,Unit2wasinMode3atnormaloperating pressureandnormaloperating temperature (NOP/NOT).
Themainsteamisolation valves(MSIVs)[EIZS:SB:V]
wereopenandvacuumexistedinthemaincondenser.
Thesteambypasscontrolsystemwasmaintaining reactorcoolant'system(RCS)[EIIS:AB]
temperature inautomatic controlandthemainfeedwater system[EIIS:SJ]
wasinoperation andmaintaining steamgenerator
[EZZS:SB:SG]
levelsautomatically onthe15percentbypassvalves[EIIS:SJ:FCV].
ThemainturbineDEHsystemhadxecentlybeenreturnedtoservicefollowing arepairtoaleakonthenumber3turbi.nethrottlevalve[EZIS:TA:FCV].
Areactorstaztupwasinprogress.
TheUnit2licensedcontrolzoomstaffconsisted oftheassistant nuclearplantsupervisor (ANPS),boardreactorcontroloperator(RCO),deskRCO,aRCOdedicated tothestartup,andaseniorreactoroperator(SRO)reactivity managerdedicated tothestartup.IAtapproximately 0345hourstherotatingmaintenance shiftsupervisor (RMSS)andsystemengineerrequested thatOperations latchtheturbinetopostmaintenance test(PMT)theworkperformed onthenumber3throttlevalve.TheANPSdiscussed thepossibility ofdelayingthePMTuntiltheturbinestartupwiththeRMSS.TheANPSdecidedtogoaheadwiththePMTinordertosavetimeincaseareworkonthevalvewasrequired.
Thenuclearplantsupervisor (NPS)andreactivity managerwereinformedoftheintention tolatchtheturbine.Atailboard wasconducted fortheturbinelatchevolution bytheANPSwiththeboardRCOandnuclearwatchengineer(NWE).Procedure GOP-201,"ReactorPlantStartup-Mode2toMode1,"wasusedasguidanceforthelatchingevolution.
TrippingoftheturbineaftezthePMTwasnotdiscussed inthebrief.At0405hours,annunciator P-17,themainsteamisolation signal(MSZS)2AS/GPressureLowChannelTripannunciator, alaxmedinthecontrolroomandthencleared.Investigation foundthattheDchannelMSISblockbistableontheengineered safetyfeatureactuation signal(ESFAS)cabinethadalsocomein.TheANPS/NPSdiscussed theoperability statusoftheeffectedchannelanddecidedthatsincethereactorwasstillinMode3,totemporarily stopthestartup.Maintenance personnel wouldperformafunctional checkontheaffectedsteamgenerator pressurechanneltoensureoperability priortoentryintoMode2.Controlelementassembly(CEA)banksA,B,1,and2werefullywithdrawn.
CEAbank3was57incheswithdrawn.
CEAbanks4and5werenotwithdrawn.
Theprojected entryinto-Mode2wasthenextrodwithdrawal sequence.
At0412hours,theturbinewaslatchedwithoutincident.
Atapproximately 0420hours,thewatchengineercalledthecontrolroomandsaidthatthePMTwascompleted andthatthetuzbinecouldbetripped.TheANPSdirectedthewatchengineertotriptheturbinelocally.Aftertheturbinewastripped,theboardRCOcheckedthe15percentbypassvalves,butdidnotresetthevalvesbecausethecontroller outp'uthadnotchanged.TheANPSwasinformedthatthecontxoller outputhadnotchangedandthevalveshadnotbeenre'set.Thewatchengineerwasalsoinformedthatthe15percentvalveshadnotbeenresetwhenheenteredthecontrolroom.Shortlythereafter, theANPSleftthesurveillance areatodiscusstheDchannelsteam'generator lowpressurebistabletroubleshooting statuswith,theOperations Manager.TheboardRCOleftthevicinityofthefeedstationtoinvestigate anannunciator.
At0423hoursseveralannunciators cameinwhichindicated asteamgenerator overfeedcondition including letdownlowpressure, steamgenerator highNRCFORM300A(0.1998)
'4RCFORM366A6i998)LICENSEEEVENTREPORT(LERjTEXTCONTINUATION
.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(205000389LERNUMBER(6)SEQUENTIAl REVISIONNUMBERNUMBER1999-007-00PAGE(3)Page3of5TEXT(Ifmoraspaceisrequired, useadditional copiesofNRCForm366A/(17)Description oftheEvent(cont'd)levels,andpressurizer lowlevel.Atthattime,the15percentvalveswerereset,theoverfeedwasterminated, andlevelswererestoredtonormalconditions.
Duringthetransient RCStemperature wasreducedfrom535'Fto526'F,orapproximately 9'F.CauseoftheEventThecauseofthiseventwasthattheoperators didnotutilizeexistingprocedural guidanceforturbineshutdown.
Thereisnospecificprocedure tolatchandtriptheturbinefortesting.Theoperators diduseprocedural guidancefromGOP-201,"ReactorPlantStartup-Mode2toMode1,"tolatchtheturbine.However,trippingoftheturbinewasnotdiscussed priortothecontrolroombeinginformedthatthePMTwascompleted.
Noprocedural guidancefortrippingthetu'rbinehadbeenconsidered bytheANPSorboardRCO.Whennotifiedtheturbinewasreadytobetripped,theANPSmadethedecisiontotriptheturbinewithoutconsidering whatprocedural guidancehewasusingtodothetrip.NOP-2-0030125, "TurbineShutdown-FullLoadtoZeroLoad,"steps7.41.3-7.41.6providestheguidancefortrippingtheturbineandspecifically addresses resetting the15percentbypassvalvesaftertrippingtheturbine.Contributing factorstothiseventwere:~Conservative Decision-Making:
Thecrewdecidedtoproceedwithturbinelatchevolution withareactorstartupinprogress.
nTheANPSconsidered thepossibility oftheadverseeffectsiftheturbinelatchevolution causedtheRCStocooldownduetoturbinevalvemispositioning orleakby.However,heconsidered thispossibility remoteanddecidedthePMTneededtobecompleted toensuretheturbinerollwouldnotbedelayed.TheNPSconsidered theplantstablesincethestartupwasonholdanddidnothaveanyproblemwiththeturbineevolution proceeding.
However,therewasnovalidreasontocompletethisevolution priortocompletion ofthereactorstartup.~..Pre-evolution briefing:
Thetailboard briefingfortheevolution wasnotadequate.
TheANPSconsidered theturbinelatchaminorevolution withdirectprocedural
'guidance andtherefore, didnotconsideritnecessary tousetheAP0010120,"ConductofOperations,"
CS-9checklist.
Thebriefdidnotincludeallmembersofthecontrolstaff,onlythepersonnel involvedintheevolution.
TheANPSdidnotincludethedeskRCObecausehewasperforming hisnormalshiftlydutiesandwasbehindduetotheincreased paperwork loadofthestartup.TheANPSdidnotincludethereactorstartupRCOorthereactivity managerbecausetheywerededicated toonlythestartup.However,becauseofthepossiblereactivity effectsoftheevolution, theindividuals involvedinthestartupshouldhavebeenincludedinthebrief.Onlytheturbinelatchingevolution wasdiscussed intheprejobbrief.TheANPSwasfocusedonensuringtheDEHcomputerwasproperlysetupfortheturbinelatchandtheproperturbineresponseonlatching.
GOP201,"ReactorPlantStartup-Mode2toMode1,"steps6.25-6.33werereviewedandconsidered appropriate fortheevolution.
Priortoandduringthebrief,theANPSneverconsidered trippingtheturbineorthestatusofthe15percentbypassvalvespost-trip.
NRCFOAM300A(0.1998)
NRCFORM366A6-1998lLICENSEEEVENTREPORT"(LERjTEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)St.LucieUnit2DQGKETNUMBER(2)05000389LERNUMBER(6)SEQUENTIAL REVISIONNUMBERNUMBER1999-007-00PAGE(3)Page4of5TEXTIifmorespaceisreriuired, useadditional copiesofIVRC&rm366AJ(17)CauseoftheEvent(cont'd)Othermembersofthecontrolroomstaffwereawareofthepostturbinetripstatusofthe15percentbypassvalvesandtheimportance ofresetting thevalves.Hadthebriefincludedallmembersofthecrew,itislikelysomeonewouldhavediscussed theimportance ofthepromptlyresetting thevalvesandoftheprocedural guidancetodoso.~OperatorTraining/Knowledge Level:Theoperators misinterpreted the15percentbypassvalvecontroller indication aftertheturbinetrip.The15percentbypassvalvesfailtothe5percentflowpositionfollowing aturbinetrip.Thereactorturbinegenerator board(RTGB)controller istakenoutofthecircuitbutthereisnochangeincontroller output.Theoperators mistakenly interpreted thenormalcontroller outputfollowing thetripasevidencethatthevalvewasstillfunctioning inautomatic andthatresetting.'he valves'as notnecessary.
Thethreelicensedoperators involvedintheevolution failedtore'cognize thestatusof15percentvalvespostturbinetrip.Theymisinterpreted controller outputnot,changingasindication thatthevalvehadnotrepositioned tothefivepercentflowposition.
Hadanyofthethreeoperators recognized thatthecontroller wasoutofthecircuit,andthatcontroller indica'tion remaining thesamewasanexpectedresponsewhenthevalveshadmovedtothedesignpostturbinetripposition, thenthevalveswouldhavebeenreset.~Self-Checking:
Theoperators didnotadequately followuponanunexpected plantzesponse.
Theoperators expectedtohavetoresetthe15percentbypassvalves,butdidnotfollowupwhentheexpectedcontroller responsewasnotobtained.
Theyincorrectly reasonedthatsincetheyhadtrippedtheturbinelocally,the15percentvalvesdidnotneedtobereset.Otherplantparameters thatwouldhaveconfirmed the15percent.valvepositions, suchassteamgenerator levels,werenot..closely monitored toverifyproperoperation.
TheboardRCOallowedhimselftObecomedistracted andlefttorespondtoanotherannunciator.
Additionally, other',.membersofthecontrolroomstaffwerenotbroughtintothediscussion oftheunexpected responseofthe15percentvalves.AnalysisoftheEventThiseventisbeingreportedasavoluntary LER.AnalysisofSafetySignificance FPLperformed anassessment forthiseventusingABB-CEbestestimatestandarddesigncalculations anddetermined thattheinadvertent cooldowndidnotresultinMode2conditions.
Calculationally, K,qgremainedlessthan0.99,butbecauseofuncertainties inthecalculations andinmeasurements, itispossiblethatthereactorenteredMode2.However,theplanthadareactor,startup inprogressandwasreadytoenterMode2.ThedecisiontoperformthePMTonthenumber3throttlevalveduringareactorstartupwasanonconservative reactivity management decision.
Reactivity management isaprimaryfunctionofthelicensedoperators inthecontrolroomandthisdecisionNBCFORM3BBAIB-1998)
NRCFORM366A6-1998)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILiTYNAME(1)St.LucieUnit2DOCKETNUMBER(2)05000389LERNUMBER(6)SEQUENTIAL REVISIONNUMBERNUMBER1999-007-00PAGE(3)Page5of5TEXT(Ifmorespaceisrequired, useadditional copiesofNRCFarm366A)(17)AnalysisofSafetySignificance (cont')demonstrates alackofsensitivity toreactivity management issues.Althoughthis.eventmostprobablydidnotresult'in aninadvertent modechange,thiseventdidrevealseveralfailedbarriersthatshouldhaveprecluded thecooldownevent.Theenhancements tothesefailedbarriersareaddressed inthecorrective actionsnotedbelow.Corrective Actions1.TheSROinvolvedwastemporarily removed'fromlicensedactivities inordertodeveloptherootcauseandcorrective actionsforthisevent.TheSROwasreturnedtolicenseddutiesafterde-briefing thePlantGeneralManageronthefindings.
2.Eachavailable Operations department supervisor hassignedaletterAcknowledging therequirements forAP0010120,"ConductofOperations,"
checksheet9foxprejobbriefings andtherequirements forprocedure usage(withthebalanceduewhenthepersonnel returnfzomvacations, etc.).3.Procedure NOP-1/2-0030122, "ReactorStaxtup,"
is,beingchangedtoincludestepsandcautionstonotperformanyevolution whichcouldinfluence RCStemperature andthusreactivity duringtheapproachtocriticality, 4.Operations management hasbriefedalloperations controlroomcrewsontheincident.
Thebriefingstresseda)theimportance ofthoroughp'rejobbriefings usingprocedure AP0010120,"ConductofOperations,"
checksheet'9;b)thenecessity ofusingtheappropriate procedure foreveryevolution andeverypart,ofeveryevolution; c)theimportance ofself-checking andfollowing uponunexpected plantresponses byuseofdiverseindications toensureequipment status,and;d)theimportance ofconservative reactivity management duringxeactorstartup.5.ATrainingBriefonoperation ofthe15percentbypassvalvesisbeingissuedtoensurealllicensedoperators knowtheoperation andRTGBindications ofthe..valvesafteraturbinetrip.6.'peration ofshutdown/low powerfeedwatercontrolisbeingincorporated intothe'Licensed OperatorContinuing Traini.ng Programtoensurealloperators areawareoftheoperating characteristics andRTGBindications offeedsystem.7.Thisevent,including therootcauseanalysis, isbeingcoveredinLicensedOperatorContinuing Training.
8.Avideoofproperprejobbriefingtechniques andexpectations isbeingproducedforuseinLicensedOperatorContinuing Training.
Additional Information FailedComonentsIdentified NoneSimilarEventsNoneNRCFORM3BBAIB-1998)
