Event Notification Report for March 21, 2008

SYSTEM INJECTION DETERMINED INOPERABLE BY FAILURE TO REMOVE ELECTRICAL JUMPER PRIOR TO MODE CHANGE

"In accordance with Instrument Maintenance Instruction (IMI) 99.040, 'Auto Safety Injection (SI) Block, Feedwater Isolation Block, and Maintain Source Range In Service Jumpers,' jumpers were placed to block the SI automatic actuation logic and actuation relays during WBNs [Watts Bar Nuclear] Cycle 8 refueling outage. The automatic actuation function for SI is required in Modes 1, 2, 3, and 4 per Function 1.b of Table 3.3.2-1 of Technical Specification (TS) 3.3.2, 'ESFAS Instrumentation.' WBN entered Mode 4 at 0020 EDT on March 20, 2008 and Mode 3 at 0100 EDT on March 21, 2008. On March 21, 2008, it was discovered that the jumpers installed per IMI-99.040 had not been removed. Due to this, Limiting Condition for Operation (LCO) 3.0.3, was entered at 0913 EDT and exited at 0958 EDT when the system was restored. The jumpers being in place in Mode 4 and 3 rendered both trains of SI automatic actuation inoperable for approximately 33 hours and 38 minutes. This event is being reported under 10 CFR 50.72(b)(3)(v)(D), 'Event or Condition that could have Prevented Fulfillment of a Safety Function.'"

The licensee attributes the error to a combination of both procedural inadequacy (i.e., the step removing the jumper did not require verification) and personnel error.

The licensee informed the NRC Resident Inspector.

* * * UPDATE PROVIDED BY DOUGLAS HOLT TO JOE O'HARA AT 0213 ON 03/22/08 * * *

"This is a follow-up notification to EN#44085 to amend reported information. At 2133 on 3/21/08 when permissive P-11(Low Pressure and Low Steamline Pressure) blocks were cleared, the on-shift crew questioned the presence of the 'AUTO SI Blocked' alarm and determined that it should have been cleared when the SI automatic logic jumper was removed earlier in the day. The crew utilized the procedural guidance of GO-1 to cycle the reactor trip breakers and reinstate the automatic safety injection logic at 2206 on 3/21/08. The previous report that identified that LC0 3.0,3 was exited at 0958 EDT is to be amended. LCO 3.0.3 was exited at 2206 when SI automatic logic was completely reinstated by cycling the reactor trip breakers."

The licensee notified the NRC Resident Inspector.

Notified R2DO(Ernstes)

AUTOMATIC REACTOR SCRAM FROM A MAIN TURBINE TRIP

"Actuation of an RPS signal while the reactor was critical.

"At 1525 a generator trip signal on the main transformers initiated a reactor scram due to Turbine Stop and Control Valve fast closure. Safety relief valves operated initially to lower reactor pressure. Turbine bypass valves operated initially to lower reactor pressure. Turbine bypass valves are maintaining pressure control currently. Reactor recirc pumps A and B transferred to slow speed operation as expected. No ECCS initiations were received. Reactor level is being controlled with normal systems condensate and feedwater. Lowest level indicated was approximately -6" wide range. Level 3 initiations occurred to group 3 isolation valves. No valves operated, they are normally closed."

The site is investigating the cause of the trip. A probable cause is the "C" phase differential trip which was received from the main transformer.

All control rods fully inserted during the scram. The plant is on its normal shutdown electrical lineup.

The licensee notified the NRC Resident Inspector.

MISSING CHEMICAL AGENT ALARM DETECTOR

"On March 21, 2008 a MSARNG [Mississippi State Army Reserve National Guard] unit from Jackson, Mississippi at the United States Property & Fiscal Office (USP & FO) receiving warehouse loaded 60 M43A1 alarms for delivery to the United States Property & Fiscal Office (USP & FO) at Camp Shelby, MS. Inventory of the M43A1's was conducted at the time of packaging the detectors in Jackson, MS. All 60 M43A1's were packaged into a single white shipping container and loaded into a trailer. The shipping container was banded shut and secured inside the towed trailer. The trailer was locked during transport in an Army vehicle. The trailer containing the M43A1's was received at Camp Shelby on or about April 8, 2008. The shipping container was not tampered with and was still closed when received at Camp Shelby. An inventory was conducted at the USP & FO, Camp Shelby and it was discovered that one M43A1 detector was missing. On May 22, 2008 a financial liability investigation of property loss was initiated by the Mississippi National Guard. The Army conducted a financial investigation liability loss that was completed on August 19, 2008. The missing alarm detector was reported to the licensee on June 19, 2008. A physical search was conducted at Camp Shelby warehouse and Jackson warehouse locations with negative results. On July 18th the NGB U.S Property and Fiscal Office in Flowood Mississippi issued a memorandum dated July 18, 2008 directing a physical inventory be conducted at all USP& FO's within the state of Mississippi to search for the missing M43A1 detector. On August 19, 2008 the physical search was completed with negative results. On August 21, 2008 the Army fiscal officer performed one last search for the device at the warehouse in Camp Shelby, MS with negative results."

Based on discussion with the license RSO (Radiation Safety Officer) the lost chemical agent alarm detector activity is 250 micro-curie of Am-241.