LER-1981-093, Updated LER 81-093/01T-2:on 811226,reactor Protection Sys Vessel Low Level Trip instrument,1-B21-LT-NO17D-1,was Indicating Upscale.Caused by Personnel Failure to Recognize & Perform Tech Specs.Personnel Counseled |
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NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION UPDATE REPORT:
LICENSEE EVENT REPORT PREVIOUS REPORT DATE 1-25-82 CONTROL BLOCX: l l
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60 61 DOCKET NUVBER 68 69 EVENT DATE 74 75 REPORT DATE 80 EVENT DESCRIPTION AND PROBA8LE CONSEQUENCES h golg l On December 31, 1981, during a discussion of problems associated with non-technical l
10 l 31 i specification related instrumentation, it was brought to the duty SRO's attention thatl go g [ the RPS vessel low level trip instrument, 1-B21-LT-N017D-1, was indicating upscale.
l 0 s l A review of plant documentation revealed this problem was first identified on auxiliaqy a
o o l logs on December 26, 1981; however, the appropriate action statement was not entered.l l o l 7 l l This could have caused a f ailure to scram at 162.5 inches if additional channels woulq also fail. This event did not affect the health and safety of the public.
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NAME OF PREPARER PHONE:
LER ATTACHMENT - RO #1-81-93 Facility: BSEP Unit No. 1 Event Date: December 26, 1981 This event occurred because Operations personnel failed to recognize an identified instrument problem affecting RPS instrument 1-B21-LT-N017D-1 as requiring technical specification corrective action. As a result, the required corrective actions were not performed within the specified time frame.
On December 26, 1981, the on-duty auxiliary operator observed and recorded on the auxiliary operator's Daily Surveillance Report (DSR) a > 210" reading for the N017D-1 instrument, which was significantly higher than shown by the other redundant level instruments. This person failed to recognize the operability requirement associated with the instrument; consequently, he did not alert the Control Operator to the problem either by word of mouth or submission of a Work Request and Authorization form to investigate and repair the problem.
In addition, the Control Operator and Shift Foreman, in reviewing the auxiliary operator's Daily Surveillance Report, also failed to recognize that a possible problem existed.
This sequence of these events was duplicated on December 27, 1981.
On December 28, 1981, a different auxiliary operator identified and documented this problem in the auxiliary operator's DSR. He also submitted a Work Request and Authorization form to investigate and repair the instrument.
In reviewing the Work Request and Authorization form, the on-duty Senior Control Operator failed to recognize this was N017D-1, a technical specification related instrument. Therefore, the correct action statement was not entered.
On December 29, 1981, a Work Request and Authorization form was written on B21-LT-N017D-2, a non-technical specification related instrument, which stated that it failed to upscale. While repair work was in progress on N017D-2 on December 31, 1981, a discussion between Maintenance personnel and the on-duty Control Operator alerted him to the questionable operability of N017D-1 which was also pegged high. Following an immediate review of the technical specification requirements involving the operability of N017D-1, a half scram was manually initiated on channel B.
As a result of this event, the involved personnel were counseled concerning 2
the importance of immediate identification and notification of any abnormal indications relating to technical specification instruments and a more thorough review of Work Authorization and Request form documentation for applicability to technical specifications.
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In addition, the following corrective actions have been accomplished or are in
. progress in an effort to prevent future events of this type:
1.
The Control Operator and auxiliary operator DSRs have been thoroughly reviewed and extensively revised. Where practical, the responsibility for technical specification related surveillance responsibility has been assigned to the Control Operator.
In both DSRs, applicable technical specification tolerances have been identified.
In addition, all required monthly surveillances are identified in separate pts and do not appear in either DSR. Also, where applicable, all instrument channel checks are now performed by comparison with similar required instrument indications.
2.
A new procedure has been developed with expected implementation by July 31, 1982, to provide a cross reference of technical specification related plant instrumentation. This procedure will define which instruments comprise a particular reactor instrumentation trip channel in order to provide the Control Operator with a more concise understanding of each required technical specification's action statement in a uniform and timely manner. All licensed personnel will receive instruction on the use of this procedure.
3.
Each operating shift has conducted a thorough review of this event with emphasis on the need to be alert to changes in plant instrumentation trending.
In addition, an on-shift seminar with each operating shift was conducted which covered DSR readings and trending, the basis and purpose of instrumentation checks, and the operability concerns of recently installed analog type instrumentation.
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| 05000325/LER-1981-001, Forwards LER 81-001/01T-0 | Forwards LER 81-001/01T-0 | | | 05000325/LER-1981-001-01, /01T-0:on 810103,feed Pump Tripped on High Vessel Level Due to safety-relief Valve B21-F013G,Model 67F,lift. Caused by High Second Stage & Pilot Leakage in Valve.Pilot Valve Temporarily Replaced Until Next Scheduled Outage | /01T-0:on 810103,feed Pump Tripped on High Vessel Level Due to safety-relief Valve B21-F013G,Model 67F,lift. Caused by High Second Stage & Pilot Leakage in Valve.Pilot Valve Temporarily Replaced Until Next Scheduled Outage | | | 05000324/LER-1981-001, Forwards LER 81-001/03L-0 | Forwards LER 81-001/03L-0 | | | 05000324/LER-1981-001-03, /03L-0:on 810129,during Surveillance Testing, HPCI Sys Initiation Reactor Level Switch Actuated at Simulated Level Above Tech Spec.Caused by Components Slipping Due to Loose Set Screws on Actuator Pointers | /03L-0:on 810129,during Surveillance Testing, HPCI Sys Initiation Reactor Level Switch Actuated at Simulated Level Above Tech Spec.Caused by Components Slipping Due to Loose Set Screws on Actuator Pointers | | | 05000325/LER-1981-002-03, /03L-0:on 810114 & 0212,reactor Protection Sys Logic relays,C71-K3D & K3E,did Not de-energize When MSIV 1-B21-F028B Was Closed.Caused by Sticking Valve Position Limit Switch Actuator Arm Cam.Switch Replaced | /03L-0:on 810114 & 0212,reactor Protection Sys Logic relays,C71-K3D & K3E,did Not de-energize When MSIV 1-B21-F028B Was Closed.Caused by Sticking Valve Position Limit Switch Actuator Arm Cam.Switch Replaced | | | 05000325/LER-1981-002, Forwards LER 81-002/03L-0 | Forwards LER 81-002/03L-0 | | | 05000324/LER-1981-002-03, /03L-0:on 810104,vacuum Breaker X-18A Had Dual open-close Position Indication While in Open Position. Probably Caused by Problem W/Vacuum Breaker Position Limit Switches.Problem Will Be Resolved During Next Outage | /03L-0:on 810104,vacuum Breaker X-18A Had Dual open-close Position Indication While in Open Position. Probably Caused by Problem W/Vacuum Breaker Position Limit Switches.Problem Will Be Resolved During Next Outage | | | 05000324/LER-1981-002, Forwards LER 81-002/03L-0 | Forwards LER 81-002/03L-0 | | | 05000324/LER-1981-003-03, /03L-0:on 810108,suppression Pool Level Exceeded Specs.Caused by Valve Operator Torque Switch Out of Adjustment Allowing Leakage Into Suppression Pool.Switch Repaired | /03L-0:on 810108,suppression Pool Level Exceeded Specs.Caused by Valve Operator Torque Switch Out of Adjustment Allowing Leakage Into Suppression Pool.Switch Repaired | | | 05000324/LER-1981-003, Forwards LER 81-003/03L-0 | Forwards LER 81-003/03L-0 | | | 05000325/LER-1981-003-03, /03L-0:control Rod 26-35 on 810103,18-51 on 810113,38-31 & 22-15 on 810114 Showed Inaccurate Position Indications.Caused by Buffer Card Failure on 26-35;defective Reed Switches in Others.Card Replaced,Switches Repaired | /03L-0:control Rod 26-35 on 810103,18-51 on 810113,38-31 & 22-15 on 810114 Showed Inaccurate Position Indications.Caused by Buffer Card Failure on 26-35;defective Reed Switches in Others.Card Replaced,Switches Repaired | | | 05000325/LER-1981-003, Forwards LER 81-003/03L-0 | Forwards LER 81-003/03L-0 | | | 05000324/LER-1981-004, Forwards LER 81-004/03L-0 | Forwards LER 81-004/03L-0 | | | 05000324/LER-1981-004-03, /03L-0:on 810110,during Startup,Intermediate Range Monitor a Did Not Respond to Changes in Input Signal.Monitor C Indicated Downscale When on Range 7.On 810111 Monitor E Indicated Downscale While Monitor C Still Inoperable | /03L-0:on 810110,during Startup,Intermediate Range Monitor a Did Not Respond to Changes in Input Signal.Monitor C Indicated Downscale When on Range 7.On 810111 Monitor E Indicated Downscale While Monitor C Still Inoperable | | | 05000325/LER-1981-004, Forwards LER 81-004/03L-0 | Forwards LER 81-004/03L-0 | | | 05000325/LER-1981-004-03, /03L-0:on 810118,during Control Rod Operability Check,Pt 14.1,rod 26-07 Would Not Select.Caused by Loose Solder Joint in Rod Select Switch Due to Frequent Use of Switch.New Solder Joint Made | /03L-0:on 810118,during Control Rod Operability Check,Pt 14.1,rod 26-07 Would Not Select.Caused by Loose Solder Joint in Rod Select Switch Due to Frequent Use of Switch.New Solder Joint Made | | | 05000325/LER-1981-005, Forwards LER 81-005/03L-0 | Forwards LER 81-005/03L-0 | | | 05000325/LER-1981-005-03, /03L-0:on 810101,during Normal Surveillance, Discovered Secondary Containment 20 Ft Elevation Inner Air Lock Door Inoperable Due to Missing Gasket Sealing Matl. Caused by High Personnel Traffic.Gasket Replaced | /03L-0:on 810101,during Normal Surveillance, Discovered Secondary Containment 20 Ft Elevation Inner Air Lock Door Inoperable Due to Missing Gasket Sealing Matl. Caused by High Personnel Traffic.Gasket Replaced | | | 05000324/LER-1981-005-03, /03L-0:on 810113,during Normal Surveillance, Secondary Containment 20-ft Elevation Outer Air Lock Personnel Door Found Not Sealing.Caused by Heavy Personnel Traffic Through Door.Gasket Repaired | /03L-0:on 810113,during Normal Surveillance, Secondary Containment 20-ft Elevation Outer Air Lock Personnel Door Found Not Sealing.Caused by Heavy Personnel Traffic Through Door.Gasket Repaired | | | 05000324/LER-1981-005, Forwards LER 81-005/03L-0 | Forwards LER 81-005/03L-0 | | | 05000324/LER-1981-006-03, /03L-0:on 810115,when Main Steam Line Isolation Valve F028C Reopened During Test P.T.1.3.1P-2,main Steam Line C Indicated Min Flow.Cause Undetermined.Investigation Will Be Performed During Future Outage | /03L-0:on 810115,when Main Steam Line Isolation Valve F028C Reopened During Test P.T.1.3.1P-2,main Steam Line C Indicated Min Flow.Cause Undetermined.Investigation Will Be Performed During Future Outage | | | 05000324/LER-1981-006, Forwards LER 81-006/03L-0 | Forwards LER 81-006/03L-0 | | | 05000325/LER-1981-006, Forwards LER 81-006/03L-0 | Forwards LER 81-006/03L-0 | | | 05000325/LER-1981-006-03, /03L-0:on 810101,containment Atmospheric Monitor, 1-CAC-ATH-1259-2 Found Out of Calibr.Caused by Instrument Drift.Monitor Recalibr & Returned to Svc | /03L-0:on 810101,containment Atmospheric Monitor, 1-CAC-ATH-1259-2 Found Out of Calibr.Caused by Instrument Drift.Monitor Recalibr & Returned to Svc | | | 05000324/LER-1981-007, Forwards LER 81-007/03L-0 | Forwards LER 81-007/03L-0 | | | 05000325/LER-1981-007-03, /03L-0:on 810220,observed 2-inch Discrepancy Between Level Indicators of Suppression Pool Level Transmitters 1-CAC-LT-2601 & 2602.Caused by Insufficient Venting of 2602 Transmitter High Side Sensing Line | /03L-0:on 810220,observed 2-inch Discrepancy Between Level Indicators of Suppression Pool Level Transmitters 1-CAC-LT-2601 & 2602.Caused by Insufficient Venting of 2602 Transmitter High Side Sensing Line | | | 05000325/LER-1981-007, Forwards LER 81-007/03L-0 | Forwards LER 81-007/03L-0 | | | 05000324/LER-1981-007-03, /03L-0:on 810115,Group 1 Isolation Signal Received on Reactor Protection Sys Trip Channel B.Caused by Failure of Relay Coil,Model P/N 12HFAS1A49F Due to Insulation Breakdown.Coil Replaced | /03L-0:on 810115,Group 1 Isolation Signal Received on Reactor Protection Sys Trip Channel B.Caused by Failure of Relay Coil,Model P/N 12HFAS1A49F Due to Insulation Breakdown.Coil Replaced | | | 05000325/LER-1981-008-03, /03L-0:on 810106,while Performing Primary Containment Leak Rate Testing of Personnel Airlock Doors, Discovered That Drywell Exterior Airlock Door Leakage Rate Exceeded Limits.Caused by Tubing Fitting Lodged in Door | /03L-0:on 810106,while Performing Primary Containment Leak Rate Testing of Personnel Airlock Doors, Discovered That Drywell Exterior Airlock Door Leakage Rate Exceeded Limits.Caused by Tubing Fitting Lodged in Door | | | 05000325/LER-1981-008, Forwards LER 81-008/03L-0 | Forwards LER 81-008/03L-0 | | | 05000324/LER-1981-009-04, /04T-0:on 810128,radwaste Sys Liquid Effluent Discharge High Range Indicator/Recorder Found to Have Recorded Release Rate Less than Actual,Causing Tech Spec Limit to Be Exceeded.Caused by Loose Mechanical Linkage | /04T-0:on 810128,radwaste Sys Liquid Effluent Discharge High Range Indicator/Recorder Found to Have Recorded Release Rate Less than Actual,Causing Tech Spec Limit to Be Exceeded.Caused by Loose Mechanical Linkage | | | 05000325/LER-1981-009, Forwards LER 81-009/03L-0 | Forwards LER 81-009/03L-0 | | | 05000325/LER-1981-009-03, /03L-0:on 810115,sys Oil Cooler Inlet Isolation Valve 1-E51-F046 Would Not Open from RTGB Resulting in Reactor Core Isolation Cooling Inoperability.Caused by Incorrect Motor Control Ctr Key Lock Switch Position | /03L-0:on 810115,sys Oil Cooler Inlet Isolation Valve 1-E51-F046 Would Not Open from RTGB Resulting in Reactor Core Isolation Cooling Inoperability.Caused by Incorrect Motor Control Ctr Key Lock Switch Position | | | 05000324/LER-1981-009, Forwards LER 81-009/04T-0 | Forwards LER 81-009/04T-0 | | | 05000325/LER-1981-010, Forwards LER 81-010/03L-0 | Forwards LER 81-010/03L-0 | | | 05000325/LER-1981-010-03, /03L-0:on 810120,upon Auto Initiation After Reactor Scram,Rcic Turbine Failed to Accelerate to Idle Speed,Making RCIC Inoperable.Caused by Dirty Contacts in Turbine Steam Inlet Supply Valve 1-E51-F045.Contacts Cleaned | /03L-0:on 810120,upon Auto Initiation After Reactor Scram,Rcic Turbine Failed to Accelerate to Idle Speed,Making RCIC Inoperable.Caused by Dirty Contacts in Turbine Steam Inlet Supply Valve 1-E51-F045.Contacts Cleaned | | | 05000324/LER-1981-010, Forwards LER 81-010/03L-0 | Forwards LER 81-010/03L-0 | | | 05000324/LER-1981-010-03, /03L-0:on 810120,RHR Svc Water Subsys a Suction valve,2-SW-V101,would Not Open Fully.Caused by Two Hex Nuts on Input Shaft of Valve Motor Operator,Model H3BC-SMB-00, Freezing to Shaft.Nuts & Shaft Reworked & Lubricated | /03L-0:on 810120,RHR Svc Water Subsys a Suction valve,2-SW-V101,would Not Open Fully.Caused by Two Hex Nuts on Input Shaft of Valve Motor Operator,Model H3BC-SMB-00, Freezing to Shaft.Nuts & Shaft Reworked & Lubricated | | | 05000324/LER-1981-011-03, /03L-0:on 810120 & 0123,actual Pool Level Determined in Excess of Upper Tech Spec Limit.Caused by Improper Calibr Data & Calibr Procedure Inadequacy.Procedure Revision Underway & Indicators Correctly Calibr | /03L-0:on 810120 & 0123,actual Pool Level Determined in Excess of Upper Tech Spec Limit.Caused by Improper Calibr Data & Calibr Procedure Inadequacy.Procedure Revision Underway & Indicators Correctly Calibr | | | 05000324/LER-1981-011, Forewards LER 81-011/03L-0 | Forewards LER 81-011/03L-0 | | | 05000325/LER-1981-011-03, /03L-0:on 810121,during Routine Shutdown Operation,Seat Leakage Discovered on Reactor Recirculation Sample Inboard Isolation Valve 1-B32-F019.Cause Unknown. Valve Will Be Inspected & Repaired During Next Outage | /03L-0:on 810121,during Routine Shutdown Operation,Seat Leakage Discovered on Reactor Recirculation Sample Inboard Isolation Valve 1-B32-F019.Cause Unknown. Valve Will Be Inspected & Repaired During Next Outage | | | 05000325/LER-1981-011, Forwards LER 81-011/03L-0 | Forwards LER 81-011/03L-0 | | | 05000324/LER-1981-012-03, /03L-0:on 810320,wiring Deficiency Associated W/ Actuation Switch Discovered That Prevented Switch Operation. Caused by Improper Writing of Field Revision to Plant Mods Requiring Installation of Switches | /03L-0:on 810320,wiring Deficiency Associated W/ Actuation Switch Discovered That Prevented Switch Operation. Caused by Improper Writing of Field Revision to Plant Mods Requiring Installation of Switches | | | 05000325/LER-1981-012-03, /03L-0:on 810122,rod 26-35 Did Not Have Position Indication at Position 03 & Rod 34-35 Did Not Have Position Indication at Position 02.Caused by Defective Rod Position Indication Reed Switches.Corrective Maint Will Be Comple | /03L-0:on 810122,rod 26-35 Did Not Have Position Indication at Position 03 & Rod 34-35 Did Not Have Position Indication at Position 02.Caused by Defective Rod Position Indication Reed Switches.Corrective Maint Will Be Completed | | | 05000325/LER-1981-012, Forwards LER 81-012/03L-0 | Forwards LER 81-012/03L-0 | | | 05000324/LER-1981-012, Forwards LER 81-012/03L-0 | Forwards LER 81-012/03L-0 | | | 05000324/LER-1981-013-03, /03L-0:on 810119,HPCI Sys Component Test Tp 9.3.a Could Not Be Completed.Caused by Failed Motor on CST Suction Valve F004.Motor Sent to Svc Contractor to Be Repaired | /03L-0:on 810119,HPCI Sys Component Test Tp 9.3.a Could Not Be Completed.Caused by Failed Motor on CST Suction Valve F004.Motor Sent to Svc Contractor to Be Repaired | | | 05000324/LER-1981-013, Forwards LER 81-013/03L-0 | Forwards LER 81-013/03L-0 | | | 05000325/LER-1981-013, Forwards LER 81-013/03L-0 | Forwards LER 81-013/03L-0 | | | 05000325/LER-1981-013-03, /03L-0:on 810122,rod Worth Minimizer Sys Rod Blocks Were Received W/Proper Adherence to Control Rod Pattern Pull Sheet.Caused by Inadequate Procedures.Rods Pulled to Correct Position | /03L-0:on 810122,rod Worth Minimizer Sys Rod Blocks Were Received W/Proper Adherence to Control Rod Pattern Pull Sheet.Caused by Inadequate Procedures.Rods Pulled to Correct Position | |
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