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 SiteStart dateTitleDescription
05000498/LER-2017-002South Texas22 January 2018Unit 1 Condition Prohibited by Technical Specifications Due to Inoperable Control Room Envelope Makeup Filtration System Heating Coil
LER 17-002-00 for South Texas Project, Unit 1, Regarding Condition Prohibited by Technical Specifications Due to Inoperable Control Room Envelope Makeup Filtration System Heating Coil

On November 23, 2017, a routine surveillance on the South Texas Unit 1 Train "C" Control Room Makeup and Cleanup Filtration System failed due to the Train "C" control room makeup filtration system heater de-energizing approximately two minutes after actuation. The makeup filtration system heater de-energized due to an improperly configured jumper on a circuit board associated with the Train "C" control room makeup filtration unit outlet low flow switch. The circuit board had been installed with the improperly configured jumper on September 27, 2017. The circuit board was properly configured and returned to service on November 24, 2017.

This resulted in the Train "C" Control Room Makeup and Cleanup Filtration System being inoperable for 58 days; the associated Technical Specification allowed outage time for this condition is 7 days. The cause of the event is the maintenance work instructions did not include steps to: (1) ensure that the circuit board jumper is in the correct position, and (2) conduct a post-maintenance test to ensure proper operation of the heaters. As a corrective action, the applicable maintenance work instructions will be revised to (1) ensure that the circuit board jumper is in the correct position, and (2) conduct a post-maintenance test to ensure proper operation of the heaters.

05000390/LER-2017-014Watts Bar30 October 2017
20 December 2017
Main Control Room Boundary Door Left Open Leading to a Loss of Safety Function
LER 17-014-00 for Watts Bar, Unit 1, Regarding Main Control Room Boundary Door Left Open Leading to a Loss of Safety Function

On October 30. 2017. at 0942 Eastern Daylight Time (EDT) Watts Bar Nuclear Plant (WBN) operations personnel received a Main Control Room (MCR) alarm for low control room positive pressure. At 0943 EDT, a Control Room Envelope (CRE) door was found ajar and immediately closed. Technical Specification 3.7.10 Control Room Emergency Ventilation System (CREVS) was declared not met for both trains, and Limiting Conditions for Operation (LCO) Condition B was entered for Unit 1 (Mode 1) and Condition G was entered for Unit 2 (Mode 5). At 0945 EDT the alarm cleared, CREVS was declared operable and LCO 3.7.10, Conditions B and G were exited. The loss of the control room envelope is being reported as a loss of safety function needed to mitigate the consequences of an accident.

The cause of this issue is a human performance error in that an individual leaving the control building complex failed to confirm closure of the MCR envelope boundary door. Corrective actions have been generated to develop and install an engineering feature to inform personnel closing the door that it is fully shut and latched.

05000254/LER-2017-003Quad Cities21 September 2017
17 November 2017
Control Room Emergency Ventilation Air Conditioning Piping Refrigerant Leak Due to High Cycle Fatigue
LER 17-003-00 for Quad Cities, Unit 1, Regarding Control Room Emergency Ventilation Air Conditioning Piping Refrigerant Leak Due to High Cycle Fatigue

On 09/21/2017 at 1550, Operations started Control Room Emergency Ventilation (CREV) Air Conditioning (AC) for Tracer Gas Testing. Per Operations instructions, Mechanical Maintenance went to inspect the Control Room Emergency Ventilation system for refrigerant leaks before Tracer Gas Testing was started. Mechanical Maintenance reported a refrigerant leak on the discharge piping of the compressor, right above the inlet to the condenser. The leak was at the expansion joint of a fitting. The safety significance of this event was minimal.

The cause of the refrigerant leak on the Control Room Emergency Ventilation compressor discharge pipe fitting into the condenser was due to high cycle fatigue.

The corrective action was to replace the failed Control Room Emergency Ventilation compressor discharge pipe fitting.

The CREV AC system is a single train system. Given the impact on the CREV AC system, this report is submitted in accordance with the requirements of 10 CFR 50.73(a)(2)(v)(D), which requires the reporting of any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

05000390/LER-2017-007Watts Bar9 June 2017
8 August 2017
Multiple Unreported Potential Loss of Safety Function Events Associated with Inoperable Single Train Systems Due to Misinterpretation of Reporting Guidance
LER 17-007-00 for Watts Bar, Unit 1, Regarding Multiple Unreported Potential Loss of Safety Function Events Associated with Inoperable Single Train Systems Due to Misinterpretation of Reporting Guidance

On June 9, 2017. Watts Bar Nuclear Plant (WBN) personnel determined that the reporting requirements of 10 CFR 50.72(b)(3)(v) and 10 CFR 50.73(a)(2)(v), as clarified by guidance in NUREG-1022, Revision 3. were being incorrectly applied for certain events associated with single train safety systems. When events occurred that resulted in these systems not meeting Technical Specification (TS) Limiting Conditions for Operation (LCO). the short duration of these events relative to their required action completion time, coupled with prompt return to allowable values, were not considered a loss of safety function by Operations and Licensing personnel. As a result, multiple potential loss of safety function events were not reported as required. These events were related to Refueling Water Storage Tank (RVVST) level, Containment and Shield Building pressure, and Control Room Envelope integrity.

A review of these events indicate, when considering the actual system capability and the response of equipment and personnel. a loss of safety function capability impacting public health and safety did not occur for events associated with the RWST, Containment. Shield Building, or Control Room. Corrective actions include briefing personnel on the regulatory impact of these events, and the importance of the control room boundary.

.._ _ NRr, FORM Kri 2017:

05000325/LER-2017-003Brunswick5 June 2017
2 August 2017
Control Room Air Conditioning and Emergency Ventilation Systems Rendered Inoperable
LER 17-003-00 for Brunswick, Unit 1, Regarding Control Room Air Conditioning and Emergency Ventilation Systems Rendered Inoperable

On June 5, 2017, at 0930 Eastern Daylight Time (EDT), Unit 1 was in Mode 1 at 100 percent power, and Unit 2 was in Mode 1 at 87 percent power and was increasing power after a preplanned control rod improvement evolution. Maintenance personnel were inspecting dampers in the Control Room Air Conditioning (AC) system and Control Room Emergency Ventilation (CREV) system and disconnected an air supply to a damper. This resulted in the CREV system being inoperable due to interruption of the pneumatic supply. The CREV system was restored to operable status by 1009 EDT. At 1352 EDT, a second damper was inspected, and its pneumatic supply was disconnected. During the second occurrence, the Control Room AC system also tripped and was made inoperable. Affected systems were restored by 1407 EDT.

The event is reportable as a loss of safety function per 10 CFR 50.73(a)(2)(v)(D). The event resulted from inadequate use of human performance tools and inadequate work instructions. Corrective actions for this event include restoring the affected pneumatic supply, revising work orders, and taking steps to emphasize proper use of human performance tools.

05000237/LER-2016-003Dresden26 May 2017Control Room Emergency Ventilation System Charcoal Filter Bank Failure to meet the Methyl Iodide Penetration Acceptance Criteria
Dresden Nuclear Power Station, Units 2 and 3, Cancellation of Licensee Event Report 237/2016-003-00, Control Room Emergency Ventilation System Charcoal Filter Bank Failure to meet the Methyl Iodide Penetration Acceptance Criteria

On 9/19/16 at 1550 CDT, test results were received indicating that a sample from the upstream charcoal filter bank of the Control Room Emergency Ventilation System (CREVS) had a Methyl Iodide Penetration of 0.65% which did not meet the Acceptance Criteria ( "Ventilation Filter Testing Program (VFTP)." As a result, CREVS was declared inoperable, and TS Limiting Condition for Operation (LCO) 3.7.4, "Control Room Emergency Ventilation (CREV) System," Condition A was entered which placed the station in a 7-day shutdown clock. On 9/20/16 at 1720 CDT, the upstream charcoal bank was replaced, all Acceptance Criteria were verified met, and TS 3.7.4, Condition A was exited. The failed sample was removed from the upstream charcoal filter on 9/12/16 at 1014 CDT. Thus, the replacement of the bank was beyond the allowed 7-day Completion Time.

This event is reportable under 10 CFR 50.73(a)(2)(i)(B), "Any operation or condition which was prohibited by the plant's Technical Specifications.

05000333/LER-2016-005FitzPatrick19 September 2016Degraded Damper Actuator Prevented Control Room Ventilation Exhaust Fan Start

On September 19, 2016, the Control Room Ventilation exhaust fan 70FN-4A did not start when it was being placed into service. The fan outlet isolation damper actuator 70MOD-108A(OP) failed to give the fully-open permissive signal to start the fan. Gentle pressure on the actuator linkage allowed the fan to start. Prior to this, on August 16, 2016, during post-maintenance testing, 70FN-4A did not start. Troubleshooting adjusted the linkage and the fan started as appropriate. However, the intermittent fan start issue was caused by the degraded damper actuator 70MOD-108A(OP). Corrective action replaced 70MOD-108A(OP).

This event is reportable per 10 CFR 50.73(a)(2)(i)(B) as a condition prohibited by Technical Specifications.

05000483/LER-2016-001Callaway20 April 2016
20 June 2016
Control Room Air Conditioning Inoperability Due To Essential Service Water Pressure Transient
LER 16-001-00 for Callaway, Unit 1, Regarding Control Room Air Conditioning Inoperability Due to Essential Service Water Pressure Transient

On 4/20/2016, Callaway received preliminary analysis results showing that during a Design Basis Accident (DBA) the 'B' Train Control Room Air Conditioning System (CRAGS) would experience a pressure transient in the associated cooling water system greater than what is experienced during Engineered Safety Feature Actuation Signal (ESFAS) testing. This condition could damage the NC unit's gaskets, as evidenced during ESFAS testing completed on 4/14/2016, resulting in the affected CRAGS and Control Room Emergency Ventilation System (CREVS) trains not being capable of performing their required safety function. This event is being reported as a condition prohibited by Technical Specifications, an unanalyzed condition, and a condition that could have prevented fulfillment of a safety function.

The root cause of the event is that the original Essential Service Water (ESW) system design did not appropriately account for water column separation and collapse pressure transients inherent during operation. Following the 'B' train ESFAS testing on 4/14/2016, more robust gaskets were installed in affected components. A complete evaluation of the pressures and dynamic forces experienced by all ESW system subcomponents will be performed. The results will be compared to current design limits, and appropriate modifications will be performed to ensure sufficient margin exists in the plant design.

05000254/LER-2015-010Quad Cities7 December 2015
5 February 2016
Loss of Control Room Emergency Ventilation System Due to Differential Pressure Switch Failure
LER 15-010-00 for Quad Cities, Unit 1, Regarding Loss of Control Room Emergency Ventilation System Due to Differential Pressure Switch Failure

system train "B" in support of planned maintenance on the non-safety related train "A". The CREV train "B" did not start. Once the CREV train "B" system failed to start, the non-safety related train "A" was restarted. Proper operation of the CREV system and CREV air conditioning (NC) systems could not be ensured, so both CREV and CREV AC system were declared inoperable. As a result, Technical Specification (TS) 3.7.4, Condition A, and TS 3.7.5, Condition A were entered.

The cause of the CREV train "B" system failure to start was the differential pressure switch, which is installed in a vibration susceptible location on the ductwork. This differential pressure switch makes up the interlock between the CREV train "B" system and the non-safety related Control Room HVAC train "A". The differential pressure switch's normally open contacts had temporarily welded together not allowing the starting signal to be received by the CREV train "B" system.

Corrective actions included replacing the differential pressure switch. A future corrective action will relocate the differential pressure switch off of the ductwork to minimize the vibration effects.

The safety significance of this event was minimal. Given the impact on the CREV system, which is common to both units, this report is submitted (for Units 1 and 2) in accordance with the requirements of 10 CFR 50.73 (a)(2)(v)(D), which requires the reporting of any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

05000220/LER-2015-004Nine Mile Point4 September 2015Automatic Reactor Scram Due to Main Steam Isolation Valve Closure

On Friday September 4th, 2015 at 09:16:04, Nine Mile Point Unit 1 automatically scrammed from approximately 100% rated power due to an inadvertent Main Steam Isolation Valve (MSIV) isolation. This event is reportable under 10 CFR 50.72 (b)(2)(iv)(B) and 10 CFR 50.73(a)(2)(iv)(A) as any event or condition that resulted in a manual or automatic actuation of any of the systems listed in 10 CFR 50.73(a)(2)(iv)(B). During quarterly surveillance testing, the MSIV failed to stop its close stroke and reopen automatically per design, due to a failed MSIV pilot test valve. The root cause of the event was an inadequate application of the designed pilot test valve for MSIV control, resulting in the pilot test valve internals binding during the surveillance test. The failed pilot valve spool and cage assembly were replaced.

The corrective action to prevent recurrence is to replace the MSIV pilot valveS with an industry proven design.

The event described in this LER is documented in the plant's corrective action program.

05000254/LER-2015-009Quad Cities27 July 2015Loss of Control Room Emergency Ventilation System Due to Air Filtration Unit Damper Failure

Emergency Ventilation (CREV) System, technicians noticed that the 'B' Air Filtration Unit (AFU) Booster Fan discharge damper became stuck in a partially open position following the 'B' AFU Booster Fan trip on a high ammonia input signal. Due to the uncertainty of being able to achieve rated airflow for the CREV System caused by recirculation that would result from running the 'A' AFU Booster Fan with the 'B' Booster Fan discharge damper partially stuck open, the CREV System was declared inoperable and surveillance testing was secured. As a result, Technical Specification 3.7.4, Condition A, was entered.

The cause of the damper failure was due to inadequate clearance between the damper seat sealing area and the damper blade to shaft fasteners which resulted in misalignment which caused the damper shaft to bend and the damper to become stuck.

Corrective actions included securing the stuck damper in the closed position and evaluating all CREV System dampers. A preventative maintenance task will be developed to stroke and inspect the dampers to identify binding; modifications will be made if necessary to other CREV System dampers to prevent binding.

The safety significance of this event was minimal. Given the impact on the CREV System, which is common to both Units, this report is submitted (for Units 1 and 2) in accordance with the requirements of 10 CFR 50.73 (a)(2)(v)(D), which requires the reporting of any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

05000254/LER-2015-007Quad Cities27 May 2015Loss of Main Control Room Envelope Boundary Due to Damper Inspection

alarm. A fire damper inspection was being performed that opened a Control Room HVAC ductwork access hatch that caused the alarm. The hatch was opened and immediately shut, re-establishing the boundary of the Control Room Envelope (CRE). The Control Room Emergency Ventilation (CREV) system was declared inoperable due to opening the ventilation duct hatch without prior administrative controls in place. As a result, Technical Specification 3.7.4, Condition C, was entered and subsequently exited within approximately one minute.

The cause of the inadvertent CRE breach was the design drawing contained in the work package that was reviewed during the Plant Barrier Impairment (PBI) screening did not adequately define the boundaries of the CRE.

Corrective actions included reviewing all open PBI packages. Associated Control Room boundary drawings and procedures will be revised to correctly annotate the proper CRE boundary to include the MCR ventilation ductwork access hatch.

The safety significance of this event was minimal. Given the impact on the MCR envelope, this report is submitted (for Units 1 and 2) in accordance with the requirements of 10 CFR 50.73 (a)(2)(v)(D), which requires the reporting of any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

05000296/LER-2014-001Browns Ferry18 March 2014Automatic Reactor Scram due to a Turbine Trip on High Moisture Separator Level

On March 18, 2014, the Browns Ferry Nuclear Plant (BFN) Unit 3 reactor automatically scrammed due to a turbine trip from a high main turbine moisture separator level. Initial indications show the level controller for 3B2 Moisture Separator failed to maintain level in automatic. Additionally, local manual control attempts failed to restore moisture separator level. Following the turbine trip Main Steam Isolation Valves remained open with main turbine bypass valves controlling reactor pressure.

At approximately 2232, Central Daylight Time (CDT) the 3B2 Moisture Separator Level High Alarm was received and an operator was dispatched to investigate. In accordance with the alarm response procedure the 3B2 Moisture Separator Water Level Controller was placed in manual. Attempts to control the Moisture Separator Reservoir 3B2 High Level Dump Valve manually were ineffective. At approximately 2252 CDT, the Unit 3 reactor automatically scrammed due to a turbine trip from a high moisture separator level.

The root cause was a failure to prevent the introduction of foreign material during the manufacturing process of the Moisture Separator Level Controller. The manufacturing defect was a legacy issue dating back to 1971 when the controller body was originally machined. The corrective actions to prevent recurrence requires the removal, cleaning of air passages, replacement of control relays, for similar controllers and upgrading the calibration procedure to include cleaning guidance.

05000395/LER-2013-006Summer4 December 2013SECURING CONTROL ROOM VENTILATION EMERGENCY RECIRCULATION WHILE ASSOCIATED RADIATION MONITOR WAS OUT OF SERVICE

On December 4, 2013, at approximately 1027 EST, 'B' train Control Room (CR) ventilation was in the emergency recirculation mode of operation as required by Technical Specification (TS) 3.3.3.1, Action 29. This Technical Specification action requires that the CR ventilation be in the emergency recirculation mode of operation when the Control Room Supply Air monitor is out of service.

An Instrument and Controls (I&C) technician was calibrating the Control Room Supply Air Atmospheric Radiation Monitor using station procedures. An operator was assisting using the system operating procedure for the Control Building Ventilation System. The (I&C) technician could not complete the test because the relay room recirculation damper position could not be verified. The technician communicated to the operator he needed to back out of the procedure. The operator mistakenly proceeded to a step in the system operating procedure to return the system to normal which resulted in securing Control Room Emergency Ventilation. The Control Room Emergency Ventilation was out of TS Action requirements for approximately 30 seconds, thus violating TS 3.3.3.1, Table 3.3-6 Action 29.

05000390/LER-2013-002Watts Bar3 May 2013Two Trains of Emergency Gas Treatment System Inoperable

On May 2, 2013 at 0845, B-train Emergency Gas Treatment System (EGTS) was removed from service for planned maintenance and Operations declared Technical Specification (TS) Limiting Condition for Operation (LCO) 3.6.9 not met and entered Condition A for one EGTS train inoperable. On May 3, 2013 at 0111, the Main Control Room was notified that the A-A Auxiliary Air Compressor Air Dryer was not purging due to failure of the Auxiliary Control Air System (ACAS) A-A dryer central timing unit. Operations declared A-train ACAS and supported Technical Specification systems inoperable, including A-train EGTS.

WBN operations entered LCO 3.0.3 due to the inoperability of two trains of EGTS and began preparations to initiate an orderly shutdown within one hour. Operations initiated actions to restore B-train EGTS to standby in accordance with System Operating Instruction (S01)-65.02, Emergency Gas Treatment System. At 0155, B-train EGTS was declared operable and the actions of LCO 3.0.3 exited. No action was taken to reduce reactor power while in LCO 3.0.3.

The A-A Auxiliary Air Compressor Air Dryer central timing unit motor was replaced. The apparent cause of this event was that there were missed opportunities to identify the need for replacement preventive maintenance (PM) for the central timing unit. Change requests have been initiated for periodic replacement of the ACAS dryer central timing unit. Components in other systems which could be subject to the same failure mechanism will be reviewed and PM activities initiated as necessary.

05000483/LER-2013-004Callaway18 April 2013Control Building Envelope (CBE) Boundary Door Open During Movement Of Irradiated Fuel Assemblies

On 04/1 8/2013, a small fire occurred at the Unit Auxiliary Transformer which caused a loss of all non-vital power to the plant during core offload. At this point in the core offload, a fuel assembly was suspended in the spent fuel pool due to a torn grid strap. The assembly was considered to be in movement since the assembly was not in a "safe" or approved storage location. As a result of the loss of power, it was desired to restore temporary power to the 'B' train battery chargers to prevent loss (discharge) of the NK02 and/or NK04 batteries. Temporary power cables were routed through three doors in the Control Building, one of which was a Control Building Envelope (CBE) pressure boundary door. With cables running through the CBE door, mitigating actions were taken to seal the opening. Such mitigating actions are allowed in Modes 1-4 per Technical Specification (TS) 3.7.10, when Condition B applies for an inoperable CBE boundary. However, allowances for mitigating actions are not permitted for an inoperable boundary during the movement of irradiated fuel assemblies. For this situation, TS 3.7.10 Condition E applies, and its Required Actions are to immediately suspend CORE ALTERATIONS (E.l) and movement of irradiated fuel assemblies (E.2). The Control Room did not immediately recognize that Required Action E.2 was in effect; therefore, there was a delay in beginning this Action of approximately 2 hours and 24 minutes. Required Action E.2 was not met since the Action was not taken without delay.

NRC FORM 356 (10.20'0)

05000368/LER-2013-002Arkansas Nuclear4 February 2013An Inoperable Emergency Control Room Chiller Due to Maintenance Error Results in a Prevented Safety Function.On February 4, 2013, at 1255 CST, Control Room Emergency Chiller 2VE-1A breaker tripped shortly after the chiller was started. 2VE-1A is one of two control room emergency chillers common to both Arkansas Nuclear One (ANO) Unit-1 and ANO Unit-2. The 2VE-1A breaker (2B-52D5) is a Siemens 480 volt, 100 amp molded case circuit breaker. An Apparent Cause Evaluation determined that the the "C" phase load side wire lug was not properly connected when the breaker was installed on November 15, 2012, resulting in a loose connection between the lug and the breaker stab. The condition was corrected and 2VE-1A was declared operable on February 6, 2013. The apparent causes of the condition were determined to be a human performance error during breaker replacement due to the inadequate use of human performance tools and an inadequate molded case circuit breaker testing procedure which did not provide a step to perform a visual inspection of the wire grip style lug after installation. Initial corrective actions included a human performance error review and a requirement for visual verification of the wire lugs for remaining breaker replacement work orders. The Apparent Cause Evaluation provided firm evidence that the condition existed since the breaker was incorrectly installed on November 15, 2012, resulting in the inoperability of 2VE-1A. The redundant 2VE-1B Chiller was considered inoperable from November 26, 2012 to December 3, 2012, resulting in the potential inoperability of both control room emergency chillers and a condition that could have prevented the fulfillment of a safety function.
05000260/LER-2012-00622 December 2012Unplanned Automatic Reactor Scram due to Loss of Power to the Reactor Protection System

On December 22, 2012, at 1152 Central Standard Time (CST), the Browns Ferry Nuclear Plant (BFN), Unit 2, reactor automatically scrammed due to actuation of the Reactor Protection System (RPS) from loss of power to both RPS buses. At 1134 CST, the 4kV Shutdown Board D unexpectedly de-energized resulting in the loss of power to the RPS 2B bus. While attempting to re-energize the RPS 2B bus, the RPS 2A bus was inadvertently de-energized resulting in the BFN, Unit 2, automatic reactor scram. During this event the Reactor Core Isolation Cooling system and the High Pressure Coolant Injection system automatically initiated as designed to restore water level above the initiation set point. All affected safety systems responded as expected for the loss of the RPS buses.

I I The root cause was that Operations' standards for the use of Error Prevention Tools were not understood nor properly applied by Operations personnel during transient plant conditions.

Corrective actions to prevent recurrence are: to develop and deliver training to provide expected behaviors for leaders and craft that support their roles and responsibilities, to perform paired observations between management and direct reports, from the level of department directors to first line supervisors, in order to verify or establish that the standards possessed by the department leaders are adequate and shared uniformly among the group, and to revise the Training Program Description for License Operator Requalification to specify that Operations Management provide training on standards and expectations for the implementation of the requirements of procedure OPDP-1, Conduct of Operations.

05000325/LER-2012-007Brunswick14 December 2012Loss of Control Room Emergency Ventilation

On December 14, 2012, at approximately 1306 hours Eastern Standard Time (EST), inoperability of both subsystems of the Control Room Emergency Ventilation (CREV) system occurred. Because Brunswick has a shared control room, this placed Unit 1 and Unit 2 in Technical Specification (TS) 3.7.3, Required Action C.1, for two CREV subsystems inoperable (i.e., be in Mode 3 within 12 hours).

At the time of the event, a modification to upgrade the Control Building fire detection system was in progress. The 2A CREV subsystem was placed in the radiation/smoke protection mode in compliance with the Technical Requirements Manual. This action prevented an auto-start of the 2B CREV subsystem and, as such, TS 3.7.3 Condition A was entered to restore 2B CREV subsystem to operable status within 7 days.

During work to electrically isolate one of the fire detectors associated with the 2A CREV subsystem, electrical continuity was lost resulting in a charcoal fire signal being sent to the 2A CREV subsystem circuitry and shutting it down. With the 2A CREV subsystem shut down due to the signal, TS 3.7.3 Required Action C.1 applied for both CREV subsystems being inoperable. Actions were taken to re-start the 2A CREV subsystem, and TS 3.7.3 Required Action C.1 was exited within approximately two minutes.

The safety consequences of this event were minimal. The condition existed for approximately two minutes, and plant staff took immediate action to return the equipment to service. The apparent cause of the event was inadequate documentation and communication of the required system alignment to support the ongoing modification.

05000254/LER-2012-0013 February 2012Control Room Emergency Ventilation Air Conditioning System Inoperable

On February 3, 2012, at 1035 hours, the Unit 1/2 (common) "B" Control Room Emergency Ventilation (CREV) Refrigeration Condensing Unit (RCU) was declared inoperable when the electrical feed breaker to the RCU was found in the tripped condition.

Operators performed required actions to safely secure the CREV RCU in accordance with procedures and training, and without complications. This resulted in entering Technical Specification 3.7.5, Condition A (30 day Action). This event affected both the Unit 1 and Unit 2 Control Rooms since they share a common control room and CREV system.

The Train B CREV Air Conditioning (AC) system is a single train safety-related system that is designed to operate in a post accident condition to maintain design temperature in the Control Room Envelope (CRE), and loss of the CREV AC could impact the plant's ability to mitigate the consequences of an accident.

The CREV RCU chiller compressor breaker trip was caused by insufficient margin in the breaker setting for MCC 18-4 Cubicle 1D. The original breaker setting did not take into account that the compressor motor load had the potential for a high locked- rotor current, and the breaker setting for instantaneous (magnetic) setting needed to be set higher to avoid nuisance trips.

Corrective actions included modifying the breaker setting under a revised evaluation.

Future corrective actions include the review of breaker settings for similar type loads, and to modify the breaker settings as deemed necessary by the evaluations.

The safety significance of this event was minimal. Given the impact on the CREV AC system, this report is submitted in accordance with the requirements of 10 CFR 50.73(a)(2)(v)(D), which requires the reporting of any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

05000325/LER-2011-003Brunswick1 December 2011Loss of Control Room Air Conditioning and Emergency Ventilation

On December 1, 2011, at 1344 hours Eastern Standard Time (EST), the Control Building (CB) instrument air dryer failed resulting in loss of control air. As a result, the three Control Room Air Conditioning subsystems required by Technical Specification (TS) 3.7.4, "Control Room Air Conditioning (AC) System," and the two Control Room Emergency Ventilation subsystems required by TS 3.7.3, "Control Room Emergency Ventilation (CREV) System," became inoperable. Because Brunswick has a shared control room, Unit 1 and Unit 2 entered TS 3.7.3 Required Action B.1, for two CREV subsystems inoperable (i.e., be in Mode 3 within 12 hours) and TS 3.7.4, Required Action E.1, for three Control Room (CR) AC subsystems inoperable (i.e., enter LCO 3.0.3 immediately). At 1410 hours, operability of two Control Room AC subsystems and one CREV subsystem was restored, and LCO 3.0.3 was exited, when the CB instrument air dryer was bypassed. No power reduction took place as a result of the LCO 3.0.3 entry.

The failure of the CB instrument air dryer was due to low refrigerant pressure leading to ice blockage of the instrument air supply line. The cause was inadequate monitoring to detect the low refrigerant pressure.

Corrective actions include replacing the instrument air dryer and a procedure revision to bypass the dryer when low refrigerant pressure conditions exist.

05000317/LER-2011-003Calvert Cliffs21 October 20111A Emeraencv Diesel Generator Inoperability Due to Water Intrusion .

On October 21, 2011, Calvert Cliffs Nuclear Power Plant discovered that a reportable condition existed. On August 28, 2011, numerous alarms were received for the 1A Emergency Diesel Generator (EDG) (train A, one of two safety-related EDGs dedicated to Unit 1). Water was intruding down the diesel generator intake piping, resulting in a short circuit on the 1A2 engine speed switch circuit. The 1A EDG was declared inoperable and appropriate Technical Specifications were implemented. The 1A2 engine speed switch assembly was cleaned, dried, and inspected. The 1A EDG was returned to operable status. Corrective actions include repair of the affected piping penetrations.

A root cause analysis determined the most probable root cause to be the penetration around the 1A2 engine combustion air intake pipe on the 80 foot level of the 1A EDG Building was unable to perform its design function of being leak tight. This may have occurred due to improper installation, manufacturing defect, degradation, or original design considerations. This condition may have existed since construction of the 1A EDG Building in 1996. There have been no licensee event reports for similar events at Calvert Cliffs.

05000254/LER-2011-003Quad Cities6 July 2011Control Room Emergency Ventilation Air Conditioning System Inoperable

On July 6, 2011 at 1410 hours, the Unit 1/2 (common) "B" Control Room Emergency Ventilation (CREV) Refrigeration Condensing Unit (RCU) was declared Inoperable due to an increase in vibration amplitude caused by a broken chiller compressor connecting rod. Operators performed required actions to safely secure the CREV RCU in accordance with procedures and training, and without complications. This resulted in entering Technical Specification 3.7.5, Condition A (30 day Action). This event affected both the Unit 1 and Unit 2 Control Rooms since they share a common control room and CREV system.

The Train B CREV Air Conditioning (AC) system is a single train safety-related system that is designed to operate in a post- accident condition to maintain design temperature in the Control Room Envelope (CRE), and loss of the CREV AC could impact the plant's ability to mitigate the consequences of an accident.

The CREV RCU chiller compressor connecting rod failure was caused by flooded starts of the compressor. The root cause of the flooded start was an unanticipated failure mode for the design application of the system.

Corrective actions included replacing the failed compressor with a new compressor, and revising the frequency for vibration analysis on the B CREV RCU to monthly. Future corrective actions include installation of an automatic pump-down modification for the B CREV RCU compressor.

The safety significance of this event was minimal.

Given the impact on the CREV AC system, this report is submitted in accordance with the requirements of 10 CFR 50.73(a)(2)(v)(D), which requires the reporting of any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

05000259/LER-2011-002Browns Ferry28 April 20111 of 12 I

On April 28, 2011, at 2338 hours Central Daylight Time, with all three units in cold shutdown and power supplied to the 4-kV shutdown buses by onsite emergency diesel generators (EDGs), Browns Ferry Nuclear Plant personnel performed a shutdown of the Unit 1/2 C EDG. The Unit 1/2 C EDG was shutdown due to a hydraulic oil leak in piping for the EDG governor that was causing voltage and frequency fluctuations. Following shutdown of the Unit 1/2 C EDG, the 4-kV shutdown board C, which was being powered by the Unit 1/2 C EDG, de-energized. This resulted in a loss of power to the 1B Reactor Protection System causing a Primary Containment Isolation System (PCIS) actuation. The PCIS isolation (Group 2) caused the loss of Shutdown Cooling on Unit 1 for 47 minutes. In addition, the loss of power to the 4-kV shutdown board C also caused the loss of the 2B Residual Heat Removal (RHR) pump leading to a momentary suspension of Shutdown Cooling for Unit 2. Shutdown Cooling for Unit 2 was immediately restored using the 2D RHR pump. The root cause of the oil leak was determined to be a less than adequate design of the Unit 1/2 C EDG governor oil piping to compensate for vibration I loading.

This report also constitutes a 10 CFR 21 notification.

05000325/LER-2011-001Brunswick7 April 2011Loss of Control Room Emergency Ventilation

On April 7, 2011, at approximately 1740 hours Eastern Daylight Time (EDT), a loss of the Control Room Emergency Ventilation (CREV) system occurred. At the time of the event, the plant was performing OMST- DG13R, "DG-3 Loading Test." During performance of this test, the 480 VAC Emergency Bus E-7 main feeder breaker tripped unexpectedly. As a result, the CREV emergency makeup damper 2-VA-2J-D-CB closed on loss of power, resulting in two CREV subsystems required by TS 3.7.3, "CREV System," being inoperable. This condition could have prevented the fulfillment of the safety function for this system. BSEP has a shared Control Room, but only Unit 1 was required to enter TS 3.7.3, Required Action C.1, for two CREV subsystems inoperable (i.e., be in Mode 3 within 12 hours). Unit 2 was operating in Mode 4 for a scheduled refueling outage and did not meet any applicability conditions for TS 3.7.3.

This condition is being reported as an event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

The safety consequences of this event were minimal. The condition existed for approximately one hour and 51 minutes, and plant staff took immediate action to return the equipment to service. The direct cause of the E-7 breaker trip was a spurious actuation of the solid state trip unit (i.e., no root cause could be determined).

The corrective actions included replacement of the breaker.

05000237/LER-2009-00612 November 2009Failure of Main Control Room Ventilation Due to Breaker Malfunction

Emergency Diesel Generator under-voltage and Emergency Core Cooling integrated function capabilities. The Under- Voltage / Emergency Core Cooling System logic is designed to shed and sequence selected electrical loads onto the associated Emergency Diesel Generator (EDG) in the event of a loss of offsite power to prevent overloading the EDG.

During the testing, the logic appropriately tripped the feeder breaker to motor control center 29-8, which supplies electrical power to the emergency ventilation system for the main control room. However during an attempt to reestablish the load, the feeder breaker failed to reclose. The lack of emergency power to the ventilation system rendered it incapable of performing its intended safety function. Therefore this condition is being reported as an event that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

The failed breaker was replaced. The failed breaker was sent to a vendor for analysis. Based on the troubleshooting and failure analysis, the most likely cause is a buildup of lubricant and oxidation on the secondary contact slides in the breaker cubicle. The four-year preventative maintenance activity for these types of cubicles was revised to include an activity to clean the secondary contact slides with an abrasive pad to remove the buildup of baked on lubricant and oxidation.

The safety significance of this event is minimal due to the health and safety of the public not being compromised. The capability to shut the plant down and maintain it in a safe condition was not compromised. Offsite power was available during the course of this event.

05000325/LER-2009-002Brunswick8 July 2009Valid System Actuations due to Loss of Power to Emergency Bus E2

On July 8, 2009, at 1013 hours Eastern Daylight Time (EDT), during planned preventive maintenance activities, electrical power was lost to the 4160V emergency bus E2. Emergency Diesel Generator 2 automatically started and re-energized the E2 bus. The loss of power to E2 resulted in Unit 1 Primary Containment Isolation System Groups 2, 3, 6, and 10 isolations. Per design, no Unit 2 safety system group isolations or actuations occurred. Other Unit 1 actuations included the Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation), automatic start of both trains of the Standby Gas Treatment System and automatic start of both trains of the Control Room Emergency Ventilation System. The affected equipment responded as designed.

This event occurred during activities associated with instrument calibration of an emergency bus E2 voltage transducer. Technicians performing the activity opened the wrong test switch. As a result, arcing occurred when test equipment was connected to an energized circuit. This caused the blown fuse in the C phase of emergency bus E2, which in turn caused a loss of power to the emergency bus and the E2 master/slave breaker to trip. The root cause of this event is inadequacies associated with procedure OPIC-CNV023 and the associated work order used to perform the preventive maintenance task. Corrective actions to prevent recurrence will correct identified problems with these documents.

05000250/LER-2009-001Docket Number1 April 2009Procedure Inadequacy Causes Control Room Ventilation Isolation Technical Specification Noncompliance

On April 1, 2009, with Unit 3 in Mode 6 and core alteration and irradiated fuel movement in containment in progress, Operations personnel identified a noncompliance with Technical Specification (TS) Limiting Condition for Operation 3.3.2, Table 3.3-2, Functional Unit 9.a, Control Room Ventilation Isolation. TS Table 3.3-2, Functional Unit 9.a, requires both actuation logic channels to be operable during core alteration. One channel of actuation logic was rendered inoperable by procedure for the Engineered Safeguards Integrated Test (ESIT) which was being performed concurrently with core alteration. With one actuation logic channel inoperable, the actions of TS 3.9.13 are to be taken.

TS 3.9.13, Action b, requires the Control Room Emergency Ventilation System (CREVS) to be isolated and placed in the recirculation mode of operation. Upon identification of this TS noncompliance, Operations personnel isolated the CREVS and placed it in the recirculation mode of operation. The apparent cause is attributed to inadequate governing procedures that focused on operability of the containment radiation monitors, not the actuating circuitry for the CREVS. Corrective action is to revise the governing procedures to ensure that TS 3.9.13, Action b, is followed when one containment ventilation isolation rack is de-energized for ESIT and core alteration is in progress. Safety significance is considered to be very low since there was no loss of safety function as one channel of CREVS actuation logic was operable.

05000259/LER-2009-00118 February 2009Turbine Trip and Reactor Scram Due To Power Load Unbalance Signal On Main Generator

February 18, 2009, at 0351 hours Central Standard Time (CST), following a scheduled preventative maintenance activity, Unit 1 reactor automatically scrammed from a turbine trip due to a power load unbalance signal on the main generator. Specifically, at 0349 hours CST, Operations swapped the Unit 1 Main Generator Isophase Bus Duct System cooling fan from the running to the alternate fan. When the alternate fan started, water entrapped in the fan housing was expelled into the bus provided a path to ground inside the bus duct.

This resulted in actuation of the generator protective relays and a turbine trip and automatic reactor scram, which resulted in the automatic actuation of the reactor protection system. Water that had settled in the idle bus duct cooling fan housing was expelled into the main generator isophase bus duct upon fan startup providing a conductive path to ground. The root cause of this event was less than adequate design process guidance for consideration of seasonal variations in the operating conditions for heating ventilation and air conditioning (HVAC) system design. The design process does not consider full range of operation of HVAC systems using raw cooling water as a cooling medium during the winter months. BFN inspected the Unit 1 isophase bus for damage. No damage was identified. BFN installed a drain with a site glass on each Unit 1 bus duct cooling fan housing. General Operating Instruction, Operations Round Logs, was revised requiring verification that there is no water in the idle fan and to drain any water that may have accumulated prior to placing it into service. BFN will modify the design change technical considerations checklist to provide design process guidance for consideration of seasonal variations in operating conditions for HVAC design.

05000325/LER-2009-001Brunswick Steam Electric Plant (Bsep)21 January 2009Loss of Control Room Air Conditioning and Emergency Ventilation System

On January 21, 2009, at approximately 1300 hours Eastern Standard Time (EST), a loss of Control Building Heating, Ventilation and Air Conditioning (HVAC) control air occurred. As a result, the two Control Room Emergency Ventilation subsystems required by Technical Specification (TS) 3.7.3, "Control Room Emergency Ventilation (CREV) System," and the three Control Room Air Conditioning subsystems required by TS 3.7.4, "Control Room Air Conditioning (AC) System," became inoperable. Because BSEP has a shared control room (CR), Unit 1 and Unit 2 entered TS 3.7.3 Required Action'C.1 (i.e., be in Mode 3 within 12 hours) and TS 3.7.4 Required Action E.1 (i.e., enter Limiting Condition for Operation (LCO) 3.0.3 immediately).

Operability of the Control Room AC subsystems and CREV subsystems was restored and related LCOs, including LCO 3.0.3 were exited at 1429 hours following the restoration of control air to the CREV system.

No reactor power reduction took place on either unit as a result of the LCO 3.0.3 entry.

The direct cause of the loss of control air to the control room ventilation system was blockage of air flow through the Control Building instrument air dryer due to freezing of condensate within the cooling coil. The freezing was due to the failure to incorporate system operating parameters for temperature into the operating procedures associated with the Control Building HVAC system. Corrective actions to prevent recurrence include revising appropriate procedures to include guidance for low temperature operation.

05000260/LER-2008-0014 October 2008Automatic Turbine Trip and Reactor Scram Resulting From a Failure of the Design Change ProcessOn October 4, 2008 at 2208 hours, Central Day Light Time (CDT) the Unit 2 reactor automatically scrammed following a turbine generator load reject signal. At approximately 2107 hours CDT, just prior to the reactor scram, operations noted the 500 kV Unit Station Service Transformer 2B tap changer operating excessively and the generator was experiencing field voltage, transfer voltage, and phase amperage swings. Operations decided to place the voltage regulator in the manual control mode in accordance with Operating Instruction, 2 01-47, Turbine-Generator System. However, when Operations transferred the voltage regulator from the auto mode to the manual mode, Unit 2 received a turbine trip and subsequent automatic reactor scram. While placing the voltage regulator in the manual mode, contacts 7 and 8 on the Voltage Regulator Auto/Manual Transfer Relay (43A relay) failed to make-up; thus, causing the turbine to trip. The root cause of this event was a failure of the design change process. The process did not provide a prompt to consider relay contact wetting and signal threshold when selecting a relay for switching low energy control signals. The event was result of the installation of a relay in an application for which it was poorly suited. TVA replaced the 43A relay in main generator voltage regulator circuit with a relay that is better suited for a low power application. TVA will revise the Technical Evaluation Considerations Checklist to address contact selection for relays installed in low energy circuits. .
05000325/LER-2008-00419 June 2008Control Room Emergency Ventilation (CREV) Subsystems Inoperable Due to Failure to Isolate

On June 19, 2008, at 1641 hours Eastern Daylight Time (EDT), the Control Room authorized post-maintenance testing following replacement of solenoid valves affecting the Control Room Emergency Ventilation (CREV) subsystem. This test inputs a simulated high radiation signal into the logic for the Control Building ventilation system to ensure that the CREV subsystem automatically aligns to the radiation/smoke protection mode. At 1735 hours, during performance of this test, the 2D Control Building exhaust fan damper failed to close and the associated Control Building exhaust fan failed to trip as expected. The affected functions of the CREV system are to provide isolation, positive pressurization, and emergency filtration of the Control Room in the event of high radiation or smoke intrusion into the Control Building.

Because BSEP has a shared Control Room, both Unit 1 and Unit 2 immediately entered TS Limiting Condition of Operation (LCO) 3.7.3, "Control Room Emergency Ventilation (CREV) System," Required Action B.1 for two CREV subsystems inoperable (i.e., be in Mode 3 within 12 hours). At 1910 hours, the 2A CREV subsystem was manually placed in the radiation/smoke protection mode restoring the subsystem to operable status, and LCO 3.7.3, Required Action B.1, was exited. No reactor power reduction took place on either unit as a result of the LCO entry.

An exact root cause for this event has not been determined. The select cause of this event was determined to be failure to identify appropriate Preventive Maintenance (PM) routes for the CREV system components. The corrective action to prevent recurrence is to develop PM tasks for the Control Building ventilation system dampers, actuators, limit switches, and relays.

05000325/LER-2008-0023 June 2008Loss of Two Control Room Air Conditioning (AC) Subsystems

At 1313 hours EDT on June 3, 2008, two operating Control Room Air Conditioning subsystems, required by Technical.

Specification (TS) 3.7.4, "Control Room Air Conditioning (AC) System," tripped during the replacement of a solenoid valve for the Unit 1 Cable Spread Room supply/exhaust fan dampers. The trip occurred when the control air supply line was momentarily uncapped to enable the installation of the control air supply to the newly installed solenoid valve, causing the dampers on the two operating AC subsystems to close. With the third Control Room AC subsystem in standby with the damper closed, all Control Room AC subsystems were shut down. Because BSEP has a shared Control Room, both Unit 1 and Unit 2 immediately entered TS Limiting Condition of Operation (LCO) 3.0.3. At 1325 hours, following completion of the solenoid valve replacement, the Control Room AC subsystems were restored to operable status and LCO 3.0.3 was exited. No reactor power reduction took place on either unit as a result of the LCO.3.0.3 entry.

This event is being reported in accordance with 10 CFR 50.73(a)(2)(v)(D), as an event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident. The root cause of this event was determined to be a reliance on an Engineering Change calculation which did not adequately consider the impact of system material condition and resulted in an inadequate assessment of risk.

The corrective action to prevent recurrence is to revise the Preventive Maintenance tasks to use a Temporary Modification whenever the Control Room AC system solenoid valves are being replaced, which will allow the Control Room AC system to run on total loss of Control Room instrument air.

05000296/LER-2008-001Browns Ferry5 May 2008Unanticipated Auto-Start of Emergency Diesel GeneratorsOn May 5, 2008, at approximately 0332 hours Central Daylight Time (CDT) Emergency Diesel Generators (EDGs) 3EC and 3ED auto-started and tied to their respective shutdown boards due to an under voltage condition. Operations was in the process of returning the Unit 3 4KV Unit Board 3B to the normal supply in accordance with Operating Instruction 0-01-57A, Switchyard and 4160V AC Electrical System, when the board failed to transfer. The loss of power to Unit Board 3B resulted in a loss of power to 4KV Shutdown Boards 3EC and 3ED, 480V Reactor Motor-Operated Valve (RMOV) Board 3B, and Reactor Protection System 3B (RPS) (JC) power supply. Due to the loss of power on the shutdown boards, EDGs 3EC and 3ED started and tied to their respective shutdown boards. Unit 3 also received Primary Containment Isolation System (PCIS) Groups 3 and 6 isolations and actuations. A coincidental upscale trip of the 3A intermediate range monitor (IRM), which resulted in RPS Channel 3A half scram, in combination with the de-energizing of the RPS Channel 3B resulted in an unexpected full reactor scram. The Standby Gas Treatment (SGT) and Control Room Emergency Ventilation (CREV) systems initiated as expected. By 0352 hours CDT the reactor scram and PCIS logic was reset, the SGT and CREV Systems were returned to standby readiness. By 0944 hours CDT power was restored to 4KV Shutdown Boards 3EC and 3ED; likewise, EDGs 3EC and 3ED were secured. TVA is submitting this report in accordance with 10 CFR 50.73(a)(2)(iv)(A) as any event of condition that resulted in manual or automatic actuation of any system listed in paragraph 10 CFR 50.73 (a)(2)(iv)(B).
05000237/LER-2008-003Dresden23 April 2008Control Room Emergency Ventilation Air Conditioning System Inoperable Due To Excessive Vibration

On April 23, 2008, at approximately 2300 hours (CDT), with both Units 2 and 3 operating at approximately 100 percent power, the Control Room Emergency Ventilation Air Conditioning System was in operation to perform a post maintenance test. During the activity, the Control Room Emergency Ventilation Air Conditioning System experienced excessive vibration. Technical Specification 3.7.5, "Control Room Emergency Ventilation Air Conditioning (AC) System," was entered. The system was restored to operable status on May 1, 2008. This event is being reported in accordance with 10 CFR 50.73(a)(2)(v)(D), "Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident," as the Control Room Emergency Ventilation Air Conditioning System is a single train system.

The apparent cause is attributed to the lack of lubrication due to the oil in the compressor being displaced by refrigerant. Liquid refrigerant accumulates in the compressor due to liquid floodback during operation and flooded starts. Following the completion of the actions associated with the equipment apparent cause analysis, Plant Engineering will evaluate system operation to determine the effectiveness of the actions taken. Based on this evaluation, if it is determined that system reliability has not been improved, further actions will be developed and implement, as appropriate.

05000296/LER-2007-005Browns Ferry31 December 2007Automatic Reactor Scram Due To Main Generator Load Reject

On December 31, 2007, at 2140 hours Central Standard Time (CST), Unit 3 reactor received an automatic scram signal following a main generator load reject. The reactor scram from the generator load reject was expected. All systems responded to the scram as expected. All control rods inserted. During the initial pressure transient, which peaked at 1141 psig, six of the main steam system relief valves opened. The reactor pressure was subsequently controlled with the main steam system bypass valves. The reactor water level was controlled by the Feedwater system, the normal heat removal path through the main condenser was maintained during the event. The reactor scram was reset December 31, 2007, by 2146 hours CST.

TVA is submitting this report according to 10 CFR 50.73(a)(2)(iv)(A), as an event that resulted in a manual or automatic actuation of the systems listed in paragraph 10 CFR 50.73(a)(2)(iv)(B) (i.e., reactor protection system including reactor scram of trip, and general containment isolation signals affecting containment isolation valves in more than one system.)

05000346/LER-2007-001Docket Number16 October 2007Station Vent Radiation Monitor in Bypass due to Faulty Optical Isolation Board

On October 30, 2007, with the plant at approximately 100 percent power, it was determined that both trains of Station Vent Normal Range Radiation Monitors were inoperable for more than one hour (on two occasions) without isolating the Control Room Normal Ventilation System as required by Technical Specification (TS) 3.7.6.1. The train 2 monitor was unknowingly inoperable due to installation of a faulty optical isolation board on October 15, 2007; which caused the monitor to be in the bypass mode for approximately 13 days. This was in excess of the seven days allowed by TS 3.7.6.1 with the ventilation not isolated. The train 1 monitor was removed from service on October 16 and 22, 2007 for routine maintenance and sampling activities. On October 23, when it was determined that train 2 monitor was in bypass mode, the monitor was declared inoperable until repairs were completed on October 25.

This issue, which is due to a faulty optical isolation board and inadequate testing specified in the Post Maintenance Test Manual and Quarterly Functional Test Procedures, is being reported in accordance with 10 CFR 50.73(a)(2)(i)(B) as an operation or condition prohibited by the Technical Specifications, and 10 CFR 50.73(a)(2)(v)(D) as conditions that could have prevented fulfillment of a safety function for systems needed to mitigate the consequences of an accident.

05000259/LER-2007-009Browns Ferry12 October 2007Invalid High Level In Moisture Separator Results in Turbine Trip and Reactor Scram

On October 12, 2007, at 0803 hours central daylight time (CDT), Unit 1 automatically scrammed following a turbine trip from a 1A1 main steam system moisture separator false high level signal. At approximately 0739 hours CDT, prior to the automatic turbine trip, the Unit 1 operator received an alarm indicating a low level in the 1A1 moisture separator drain tank. At 0803 hours CDT, Unit 1 received a moisture separator 1A1 high level turbine trip signal followed immediately by a reactor scram.

WA submits this report in accordance with 10 CFR 50.73(a)(2)(iv)(A), as an event that resulted in a manual or automatic actuation of the systems listed in paragraph 10 CFR 50.73(a)(2)(iv)(B) (i.e., reactor protection system including reactor scram or trip, and general containment isolation signals affecting containment isolation valves in more than one system).

05000259/LER-2007-008Browns Ferry3 September 2007Manual Reactor Scram due to an Electro Hydraulic Control System Leak

On September 1, 2007, at approximately 1955 hours CDT, Unit 1 Operations was notified that there was a small EHC leak in the Unit 1 Moisture Separator (MS) room in the Turbine Building. Unit 1 was operating at 100 percent power. Video monitoring was established by 0657 hours CDT. Operations noted the leak rate was approximately 120 drops per minute. On September 3, 2007, at 0214 hours CDT Operations noted that the leak rate was increasing and manually scrammed the reactor from approximately 72 percent power.

This report is submitted in accordance with 10 CFR 50.73(a)(2)(iv)(A), as an event that resulted in a manual or automatic actuation of the systems listed in paragraph 10 CFR 50.73(a)(2)(iv)(B) (i.e., reactor protection system including reactor scram or trip, and general containment isolation signals affecting containment isolation valves in more than one system).

05000259/LER-2007-007Docket Number08 11 2007 2007-007-01 02 18 200911 August 2007Automatic Reactor Scram From A Neutron Monitoring Trip Signal

On August 11, 2007, at 1751 hours central daylight time (CDT) Unit 1 automatically scrammed from a .

Neutron Monitoring Average Power Range Monitor (APRM) signal. Just prior to the scram, a Reactor Recirculation system flow sensing line separated from the Recirculation Pump 1B Flow Transmitter (1-FT-068-081B). This resulted in a false indicated recirculation system low flow with a high reactor core thermal power (100 percent) to the Neutron Monitoring system. Based on these conditions, the neutron monitoring system initiated an APRM Simulated Thermal Power Flow Biased Reactor Scram.

TVA's causal analysis concluded the root cause of this event was a lack of rigorous worker practices in the use of place keeping and flagging to keep up with the work steps during the Unit 1 recovery . 1 activities. This resulted in inadequate assembly of the compression fitting,- - . . - ...:. .:-., -. ,.; - . _ .

TVA is submitting this report in accordance with 10 CFR 50.73(a)(2)(iv)(A); as ansevent-that retulted in.. .- amanual or automatic actuation of the systems listed in paragraph 10 CFR 50.73(a)(2)(iv)(B) .,

  • (i.e., reactor protection system including reactor scram or trip, and general containment isolation signals affecting containment isolation valves in more than one system).
05000259/LER-2007-005Browns Ferry9 June 2007Automatic Reactor Scram Due To Turbine Trip As A Result Of Invalid High Level In Moisture Separator Drain Tank

On June 9, 2007, at approximately 1100 hours central daylight time (CDT) Unit 1 automatically scrammed following a turbine trip from a 1A2 main steam moisture separator tank high level signal.

Prior to the scram, at 1019 hours CDT, the Moisture Separator Reservoir High Level Dump Valve was noted opening. At approximately 1040 hours CDT operations received a low level alarm for the 1A2 moisture separator. Subsequently, at approximately 1100 hours CDT a turbine trip signal was initiated from an indicated main steam moisture separator high tank level. This was followed by an automatic reactor scram. The root cause of the event is the sizing of the Moisture Separator 1A2 Level Control Dump Valve. TVA is reviewing the design for the Moisture Separator Dump Valve and controls to determine if modifications are required. If necessary will either modify or replace the Unit 1 valves and controls.

05000296/LER-2007-001Browns Ferry9 February 2007Reactor Scram Due To Low Reactor Water Level Caused By Loss Of Feedwater.At 1208 Central Standard Time, on February 9, 2007, Unit 3 received an automatic reactor scram on low water level following the loss of condensate flow. Just prior to the scram, operations attempted to establish manual operation of the condensate and demineralizer system. Personnel were in the process of modifying the control logic for the condensate and demineralized water system backwash controller. With the primary controller in run mode and the secondary controller in the program mode, personnel were loading new software into the secondary controller. The personnel involved were experiencing difficulties loading the software onto the secondary controller, so they attempted to load software onto the primary controller. They placed primary controller, which was previously in the run mode, into the program mode. However, the secondary controller was not returned to the run mode. With neither controller the run mode the condensate and demineralizer water system demineralizers isolated. This resulted in a decrease in reactor water level and an automatic reactor scram. The root cause of this event was the individuals involved in the planning and implementation of the work order did not fully understand manual operation of the system. Additionally, there is inadequate guidance or limitations on the use of in-field decision making. TVA is revising the operating instructions for the condensate demineralizer system. WA is revising trouble shooting guidance to eliminate trouble shooting under the direction of the system engineer or other individuals except under tightly controlled circumstances.
05000260/LER-2007-001Browns Ferry11 January 2007Automatic Turbine Trip and Reactor Scram Due To Equipment Failure During Performance of the Main Generator Rheostat Test.On January 11, 2007, at 0818 hours Central Standard Time the Unit 2 reactor automatically scrammed on a turbine generator load reject signal during the performance of Operating Instruction 2-01-47, Main Generator Voltage Control Rheostat Test. Just prior to the reactor scram, with the main generator voltage regulator in the automatic mode, the operations personnel were in the process of performing a rheostat cleaning operation on the generator field voltage manual adjust rheostat (70P) by cycling the rheostat to its upper limit and back to zero. Following this step, per the 01 the voltage regulator was placed in the manual mode. After a short time delay, Unit 2 received a turbine trip and subsequent automatic reactor scram. The turbine trip and reactor scram resulted from the failure of a relay in the main generator voltage regulator. During the performance of 2-01-47, a contact on the regulator mode transfer relay (43A relay) in the auto/manual portion of the main generator voltage regulator control circuit failed. WA replaced the 43A relay in the main generator voltage regulator circuit.
05000324/LER-2006-00325 December 2006Automatic Reactor Scram due to Trip from Neutron Monitoring System

On December 25, 2006, at 0539 an automatic reactor scram occurred on Unit 2 due to a Reactor Protection System (RPS) actuation. The unit was operating at 64% reactor power in single recirculation loop operation when the RPS actuated on Neutron Monitoring System Oscillation Power Range Monitors (OPRMs), channels 2 and 4. All control rods properly inserted. Reactor water level reached Low Level 1 (LL1) and Low Level 2 (LL2) as a result of the scram. The LL1 signal caused a Group 2, Group 6, and Group 8 isolation signal. All LL1 actuations occurred as designed. The LL2 signal causes a Reactor Core Isolation Cooling (RCIC) actuation, a High Pressure Coolant Injection (HPCI) actuation, a Group 3 isolation, a Secondary Containment isolation, a Standby Gas Treatment initiation (SBGT), a Control Room Emergency Ventilation (CREV) initiation, a Reactor Recirculation Pump trip, and an Alternate Rod Insertion (ARI) actuation signal. The LL2 condition was reached momentarily, and did not affect all instruments. Further evaluation concluded that the appropriate LL2 isolations and actuations occurred as designed.

This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A), as an event or condition that resulted in manual or automatic actuation of the systems listed in 10 CFR 50.73(a)(2)(iv)(B).

The root cause of this event was determined to be inadequate incorporation of Operating Experience into plant procedures and training.

05000237/LER-2006-005Docket Number8 November 2006Units 2 and 3 Control Room Emergency Ventilation Air Conditioning System Inoperable Due To Leaking Fittings

On November 8, 2006, at 2254 hours (CST), with Unit 2 at approximately 85 percent power and Unit 3 in a refuel outage, Dresden Nuclear Power Station control room personnel identified that the Control Room Emergency Ventilation Air Conditioning System failed to maintain proper control room temperature.

Technical Specification 3.7.5, "Control Room Emergency Ventilation Air Conditioning (AC) System," was entered. The system was restored to operable status on November 9, 2006 at 0555 hours (CST). This event is being reported in accordance with 10 CFR 50.73(a)(2)(v)(D), "Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident," as the Control Room Emergency Ventilation Air Conditioning System is a single train system.

The cause of the event was attributed to a loss of process fluid from the Control Room Emergency Ventilation Air Conditioning System's Refrigeration Condensing Unit due to loose instrument tube fittings caused by vibration. The corrective action to address this event is to enhance existing Control Room Emergency Ventilation Air Conditioning System inspections by establishing a new maintenance activity to perform a yearly walk down to monitor for refrigerant leaks on the Control Room Emergency Ventilation Air Conditioning System.

05000324/LER-2006-0011 November 2006Loss of Startup Auxiliary Transformer Results in Unit 2 Manual Reactor Protection System Actuation12.LICENSEE CONTACT FOR THIS LER FACILITY NAME TELEPHONE NUMBER (Include Area Code) Mark A. Turkal, Lead Engineer - Licensing (910) 457-3066 13.COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT MANU- REPORTABLE MANU- REPORTABLECAUSE SYSTEM COMPONENT CAUSE SYSTEM COMPONENTFACTURER TO EPIX FACTURER TO EPIX 14.SUPPLEMENTAL REPORT EXPECTED 15.EXPECTED MO DAY YEAR
05000368/LER-2006-001Docket Number30 October 2006Completion of a Plant Shutdown Required by Technical Specifications Due to Loss of Motive Power to Certain Containment Isolation Valves as a Result of a Phase to Ground Short Circuit in a Motor Control CubicleAt 1925 CST, on October 30, 2006, Arkansas Nuclear One, Unit 2 (ANO-2), initiated a plant shutdown as required by Technical Specifications because certain containment isolation valves were inoperable as a result of loss of their motive power. The reactor was manually tripped at 2134 CST, in accordance with the plant shutdown procedure. Power was lost to the valves at 1238 when the supply circuit breaker for 480 VAC motor control cubicle (MCC) 2B-53 tripped as a result of a bus to ground electrical fault. At 1244, operators dispatched to investigate the breaker trip discovered a small fire in the MCC, which they immediately extinguished. ANO-2 declared an Alert at 1304 due to a fire which affected one train of safety related equipment. Plant conditions remained stable at 67 percent power while the extent of damage was evaluated until 1925, when plant shutdown was initiated to facilitate repairs. The alert was terminated at 2000 on October 30, 2006. Repairs were completed and the unit returned to power operation at 0609 CST, on November 1, 2006. The root cause of this event was determined to be an inadequate MCC design that resulted in improper placement of a circuit breaker in the MCC. One of the three phase stabs did not make up to its associated bus bar correctly, resulting in a high resistance connection that caused melting of the stab's spring clip. An acceptable method for verifying proper stab engagement during breaker installation will be developed and incorporated into appropriate procedures.
05000296/LER-2006-003Browns Ferry29 August 2006Manual Scram in Response to Main Turbine Electro-Hydraulic Control (EHC) System Fluid Leak

On August 29, 2006, while in steady state operation at 100% power, control room annunciation was received at 2210 hours CDT of a low level in the main turbine electro-hydraulic control (EHC) fluid reservoir. Local inspection of the tank confirmed an actual low level and also that the tank level was continuing to drop. At 2223 hours, reactor power was reduced to approximately 78% via reactor recirculation pump speed reduction, and, at 2225 hours, a manual scram was initiated in accordance with plant procedures. All control rods fully inserted and expected system responses were received. Actuation of primary containment isolation system groups 2, 3, 6, and 8 occurred due to the expected temporary lowering of reactor water level below the actuation setpoint. Valve realignment as part of the main turbine trip which followed the scram isolated the location of the EHC fluid leak from the rest of the system. The normal heat rejection path (from the reactor to the main condenser via the main steam lines with reactor water make-up provided by the condensate/feedwater systems) remained in service.

Reactor water level was recovered to the normal operating range by the normal reactor water level control system. Neither the high pressure coolant injection nor reactor core isolation cooling systems were used during this event.

The root cause of the EHC fluid leak was determined to be inadequate 0-ring compression on a solenoid valve mounting due to the use of device mounting bolts which were too long. The bolts and the valve were supplied as a kit by the vendor. Plant procedures will be revised to verify bolt length and mounting hole depth in future activities involving EHC components.

05000296/LER-2006-002Browns Ferry19 August 2006Manual Reactor Scram Due To Loss of The Reactor Recirculation Pumps

On August 19, 2006, at 1105 hours central daylight time, Unit 3 was manually scrammed following a loss of both the 3A and 3B Reactor Recirculation pumps. Just prior to the event, the Unit 3 Unit Operator (UO) received alarms indicating low reactor water level, reactor feedwater level control system failure, and failure of the input/output modules for both the 3A and 3B Reactor Recirculation pumps. The UO also reported that main generator load was approximately 730 megawatts electrical (approximately 64 percent of full power output) and lowering. Based on these indications, the UO scrammed the reactor.

The immediate cause of the manual scram was the loss of both the 3A and 3B Reactor Recirculation pumps. The manual scram was required by the conditions presented to the Unit 3 operator following the loss of recirculation flow. The initial investigation into the trip found the Variable Frequency Drive (VFD) microprocessors non-responsive. The root cause of the event was the VFD controls malfunctioned due to excessive traffic on the connected plant Integrated Control System (ICS) network. Corrective actions include developing a network firewall device that limits the connections and traffic to any potentially susceptible devices on the plant ICS network and installing a network firewall device on each Unit's VFD controller.