United States Nuclear Regulatory Commission - Protecting People and the Environment

ACCESSION #:  9502220392
                       LICENSEE EVENT REPORT (LER)


DOCKET NUMBER:  05000250


EVENT DATE:  11/03/94   LER #:  94-005-01   REPORT DATE:  02/09/95



50.73(a)(2)(ii), (a)(2)(v), (a)(2)(vii), 10 CFR 21

NAME:  C. L. Mowrey, Licensing OEF          TELEPHONE:  (305) 246-6204




On November 3, 1994, Turkey Point Unit 3 was in Mode 1 at 100% power, and
Unit 4 was in Mode 5 during a refueling outage.  During the Unit 4
Integrated Safeguards Test, the 3A sequencer failed to respond to the
Unit 4 Safety Injection signal.  A defect was found in the sequencer
software logic which, for a limited period of time, could inhibit any or
all of the four sequencers from responding to specific valid signals.
The defect only affects the sequencers during manual or automatic
testing.  The sequencers were installed in late 1991.

Monthly manual testing of the sequencer has been resumed.  Front panel
visual examinations are being performed every 8 hours, and internal
visual examinations are being performed every 24 hours.  A permanent
repair to the software logic is being evaluated.  Independent consultants
performed an assessment of the existing sequencer design, software
design, and the Validation and Verification process.  One other software
error involving Containment Spray (CS) pump autostart was discovered, and
determined to have minimal safety significance.  The CS system remains


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On November 3, 1994, Turkey Point Unit 3 was operating in Mode 1 at 100%
power, and Unit 4 was in Mode 5 during a refueling outage.  During the
Unit 4 Integrated Safeguards Test, a failure of the 3A sequencer [JE:34]
to respond to the opposite unit's Safety Injection (SI) signal occurred.
Troubleshooting resulted in the discovery of a defect in the sequencer
software logic which, under certain conditions, could inhibit the
sequencer from responding to a valid emergency signal.  The defect
manifested itself in the failure of the 3A High Head Safety Injection
(HHSI) pump [BQ:p] to start.  Turkey Point has four HHSI pumps; one per
train, per unit.  Each HHSI pump is capable of providing 50 percent of
system requirements, therefore two of the four are required to mitigate
the consequences of accidents analyzed in the Updated Final Safety
Analysis Report (UFSAR).  In order to meet single failure criteria, each
sequencer signals its associated HHSI pump to start, and the opposite
unit's sequencers signal their associated HHSI pumps to start.  For
example, an SI signal on Unit 3, Train A, signals the 3A sequencer and
both of the Unit 4 sequencers.  With no equipment failures, all four HHSI
pumps will respond to an SI signal on either unit.

The software logic defect is limited to the test function, but the defect
is common to all four sequencers (one sequencer per train, per unit).
The design intent of the sequencers is such that should a "real"
emergency signal occur while the sequencer is being tested, the test
signal clears, allowing actuation of the Engineered Safety Features
controlled by the sequencer.

Because the sequencers would not have responded properly to an SI signal
as designed, Turkey Point Units 3 and 4 have been operating outside their
design basis.  This condition was reported to the NRCOC at 1609 on
November 3, 1994, in accordance with 10CFR50.72(b)(ii)(B).

The detailed review of the sequencer software, described in Corrective
Action #6, resulted in the discovery of one other error in the software,
which is independent of the test mode.  A potential condition was
identified which, for a remote set of circumstances, would preclude the
automatic start of the Containment Spray (CS) pumps [BE:p].  The
condition identified occurs when the Hi-Hi Containment Pressure (HHCP)
signal is received by the sequencer during an approximate 60 millisecond
(ms) time window just prior to the end of sequencer load block 3 for Loss
of Coolant Accident (LOCA) or Loss of Offsite Power coincident with LOCA
(LOOP/LOCA) events.  The sequencer is designed to autostart the CS pumps
11 to 13 seconds after an SI signal (without LOOP) if the HHCP signal is
present or at or after 44 seconds under conditions where the HHCP signal
occurs more than 13 seconds after receipt of the SI signal.  For a
LOOP/LOCA, these times are shifted by the bus stripping and EDG start
delay of approximately 16 seconds.  Thus the 60 ms window occurs 12.886
to 12.945 seconds after receipt of an LOCA signal, or 28.886 to 28.945
seconds after receipt of a LOOP/LOCA signal.

Although Turkey Point is licensed to accommodate a LOCA with or without a
concurrent LOOP, the sequencer was designed to accommodate non-concurrent
LOOP/LOCA sequences as well.  As a result, for certain non-concurrent
events, a Main Steam Line Break or a Small Break LOCA (but large enough
to cause a HHCP signal) can also create conditions under which this error
may manifest itself.

TEXT                                                         PAGE 3 OF 18

Automatic CS pump start actually involves two HHCP signals; one via the
sequencer logic as described above, and one directly from Engineered
Safety Features Actuation System (ESFAS) relay [JE:44].  Because of the
minimum pulse required to assure CS pump breaker [BE:bkr] closure, and a
potential relay race with a CS pump start permissive from ESFAS, the CS
pump breaker may not receive a close signal of sufficient duration to
assure breaker closure.  The identified condition is unique to the start
of the CS pump because the CS pump start signal duration decreases as the
postulated receipt of a HHCP signal approaches the end of load block 3.
All other sequenced equipment receives a start pulse of fixed duration,
either 2 or 5 seconds.  This condition was determined to be not
significant, in part because the manual start capability of the CS pump
is not affected (and is adequately proceduralized), and in part because
the probability of occurrence of the condition is lower than the
probability of a common-mode failure of both trains of containment spray.
The significance of the condition is discussed further in Section III.


Each of the four sequencers, 3C23A-1, 3C23B-1, 4C23A-1, and 4C23B-1, is
associated with a given train (3A, 3B, 4A, and 4B, respectively).  They
are designated Class 1E, Seismic Category I, since their operation is
required for safe shutdown of the reactor in the event of a Loss of
Offsite Power (LOOP) and to mitigate the consequences of a design basis

The sequencers are Programmable Logic Controller (PLC)-based cabinets
using a PLC for bus stripping and load logic and control.  The signal
path structure of the PLC uses dedicated input modules, control logic,
and dedicated output modules.

LOOP Signal Only

On a LOOP in a given unit, both sequencers associated with that unit will
respond accordingly to clear their associated buses, stripping all 4.16KV
loads and specified 480V loads within one second after the LOOP signal is
generated.  The Emergency Diesel Generators (EDGs) [EK:dg] will start,
and within 15 seconds the EDG output breakers [EK:bkr] close, then loads
required for safe reactor shutdown are sequentially connected to the
corresponding bus; the first load block output signal is generated 16.5
seconds after the onset of the LOOP.

LOCA Signal Only

If either unit experiences a LOCA, and preferred (offsite) power is
available, bus stripping signals and EDG breaker closure permissive
signals will not be initiated by the sequencers.  Vital loads will be
sequentially connected to the buses by the sequencers (including the
opposite unit's HHSI pumps).  If an EDG is already operating and
parallelled to offsite power, and either unit experiences a LOCA, the EDG
breaker will trip.  The EDG will continue to run in a standby condition.
On the LOCA unit, Engineered Safety Feature (ESF) equipment will be
sequentially loaded onto the bus by the sequencer.  Following a LOCA, if
any given train experiences undervoltage, bus stripping, EDG breaker
closure, and sequentially loading will be directed.

TEXT                                                         PAGE 4 OF 18


After a LOOP on both units, if one unit experiences a LOCA, the buses
associated with the LOCA unit will be stripped and ESF loads will be
loaded onto the bus.  On the non-LOCA unit, both buses are stripped
again, and reloaded with essential equipment; both HHSI pumps will also

Sequencer Testing

Each sequencer is provided with Manual test and Automatic Self-test
capability.  The test mode is determined by a three-position Test
Selector switch.  The three positions are AUTO (self-tests 15 steps or
scenarios in the automatic test sequence), MAN (each test is manually
initiated), and OFF (no test signals are generated).  In the automatic
test mode, the sequencer continuously tests the input cards, output
cards, and output relay coils, and exercises the program logic.  The
sequencer is designed to abort the manual and automatic test modes in
response to a valid input.  The automatic self-test function is normally
in operation, however it is not required to be in service for the
sequencer to perform its safety function.  The manual test, in addition
to testing all the conditions covered by the automatic test, actuates the
output relays.  However, blocking relays energize before the output
relays energize, and the output relays de-energize before the blocking
relays de-energize.

Placing the Test Selector switch in MAN stops automatic self-testing.

Manual testing involves five stripping/clearing scenarios (bus clearing,
480V undervoltage with SI present, 480V degraded voltage, 4.16KV
undervoltage, and safety injection [LOCA] on an isolated bus).  Upon
completion of the stripping tests, sequencing scenarios are tested
manually by rotation of a Sequencing Mode Test Selector switch through
eleven steps or loading scenarios (LOOP; LOOP/LOCA same train; LOOP/LOCA
other unit; LOCA same train; LOCA other unit; LOOP/LOCA same train with
concurrent HHCP; LOOP/LOCA same train with HHCP before 13 seconds;
LOOP/LOCA same train with HHCP after 13 seconds; LOCA same train with
concurrent HHCP; LOCA same train with HHCP before 13 seconds; LOCA same
train with HHCP after 13 seconds).

Automatic self-testing cycles through 15 of the 16 test steps in the same
order (the bus clearing scenario is not tested in AUTO).  The test steps
start roughly an hour apart, and there is one hour in the automatic test
sequence in which no testing takes place, so a full cycle of automatic
self-testing takes approximately sixteen hours.  Then the cycle begins
again.  Should a valid process input signal be received during manual or
automatic testing, the testing stops, the test signal clears, and the
inhibit signal is supposed to clear if present, allowing the valid signal
to sequentially energize the output relays and their associated ESF

TEXT                                                         PAGE 5 OF 18


The 3A sequencer failed to respond as expected to an opposite unit SI
signal.  The 3A sequencer had dropped out of the Automatic Self-Test
without alarming, indicating that it had received a valid input signal.
During troubleshooting, the input LED for a 4A SI signal was found to be
lit, indicating the signal was still present.  The 3A sequencer response
should have been to start the 3A HHSI pump after a 3 second delay.
However, the pump failed to start because it did not receive a start
signal from the sequencer.

Following the failure of 3A HHSI pump to start in response to a 4A SI
input signal as described above, an analysis of the sequencer software
logic was performed to determine the root cause of the failure.  A
software design defect was discovered whereby the start signal for the 3A
HHSI pump remained inhibited during sequencer automatic test step 3
(LOOP/LOCA other Unit) even though a valid process input was present.  In
parallel with the above analysis, this particular fault was duplicated on
the sequencer simulator which is identical to the 3C23A-1 (3A) sequencer.
This is in contrast to the original design bases of the sequencer
Automatic Self-Test and Manual Test functions.

The review was then expanded to include additional test modes, process
inputs, and required outputs.  It was found that the problem exists
during both manual and automatic testing, during sequencer test steps 2,
3, 6, 8, and 10.  These steps correspond to the following scenarios:

     Step 2    LOOP/LOCA

     Step 3    LOOP/LOCA other Unit

     Step 6    LOOP/LOCA with concurrent High High Containment Pressure

     Step 8    LOOP/LOCA with High High Containment Pressure less than 13
               seconds later

     Step 10   LOOP/LOCA with High High Containment Pressure more than 13
               seconds later

Note that these are tested scenarios, not potential plant events.  Note
too that all five of the affected test step scenarios involve LOOP and

If a valid SI signal is received 15 seconds or later into one of the
above tests, the test signal clears as intended, but the inhibit signal
is maintained by means of latching logic.  This latching logic is
originally established by the test signal, but may be maintained by the
process input signal if it arrives prior to removal of the test signal.

Since the above condition is applicable to both the automatic self-test
and manual testing, the sequencer must be considered inoperable during
both testing modes.  Note, however, that this defect will not cause a
sequencer operating malfunction with the Test Selector switch in any
position for any design basis scenario which involves a loss of offsite

TEXT                                                         PAGE 6 OF 18

This software logic defect was introduced during the detailed logic
design phase of the software development.  The detailed logic designer
and the independent verifier failed to recognize the interaction between
some process logic inhibits and the test logic.  The defect in the
software logic was not detected during the Validation and Verification
process (V&V) because the response to valid inputs was not tested during
all stripping and loading sequences of the automatic and manual testing
logic.  FPL has evaluated the V&V for the sequencers and concluded that
the existing V&V adequately addresses operation of the sequencers with
the Test Selector switch in OFF.

This logic defect can occur when the sequencer is in either the manual or
automatic test mode, and the test sequence currently being executed is
loading sequence test 2, 3, 6, 8, or 10.  This was determined based on a
review of the sequencer logic drawings for the 15 steps in the automatic
test sequence, and design basis event signals.  The sequencer simulator
was used to confirm the results of the review.  The defect cannot affect
sequencer operation with the Test Selector switch OFF.

In loading sequence tests 2, 6, 8, or 10, the sequencer may be inhibited
from responding to a valid SI signal on the same train.  In loading
sequence test 3, the sequencer may be inhibited from responding to a
valid SI signal on the opposite unit.


As a result of the erroneous inhibit signals, the potential exists for
any sequencer output to be prevented from being generated when required.
Exactly which output or outputs is(are) determined by a combination of
factors, i.e., which test scenario is in progress, how long since the
test scenario was initiated, and which process input or inputs are
received.  In general, for the approximate one-hour duration of each of
the above test steps (with the Test Selector switch in AUTO), the
sequencer will not respond correctly to a valid process input signal.

With the sequencer Test Selector switch in AUTO, the sequencer steps
sequentially through sixteen steps as described above; first the five bus
stripping/clearing steps, followed by the eleven LOOP and/or LOCA
scenarios.  Note that the five test steps affected by the software defect
are all in the loading sequence test steps, so the first affected step is
the seventh step in the total testing sequence.  During each of these
affected test steps, fifteen seconds after the initiation of the step,
the sequencer would not have responded properly to a valid process input
signal.  So the sequencer was inoperable for about five hours out of each
sixteen hour period as long as its Test Selector switch was in AUTO.  The
sequencer was also inoperable for the duration of any Manual test of the
five test steps listed above.  A complete manual test on one sequencer
takes about one hour.

TEXT                                                         PAGE 7 OF 18


Test Logic Defect
The review of the sequencer logic determined that improper operation of
the sequencer could occur for only certain sequencer stripping/loading
scenarios in which an SI signal without LOOP occurs.  The sequencer logic
software defect does not affect any scenarios where a LOOP also occurs,
whether before, after, or concurrent with an SI signal.  A failure modes
and effects matrix identified the following four potential plant events
where the logic software defect could affect the operation of the
sequencer, depending upon which of the five affected test steps
(discussed above in II. CAUSE OF THE EVENT,) are being performed when the
SI signal is received by the sequencer:

     #1   LOCA Same Train

     #2   LOCA on other Unit

     #3   LOCA w/High High Containment Pressure (HHCP) < 13 seconds

     #4   LOCA w/HHCP > 13 seconds

Note that these are potential plant events, not test step scenarios.
Note too that in contrast to the list of affected test step scenarios
presented earlier, none of the potential plant events affected involve a

For each of these events, the sequencer could receive a valid SI signal
but the logic defect could inhibit the sequencer from starting equipment.
Events #1, #3, and #4 above each have four logic test steps out of a
total of sixteen which would inhibit the sequencer from providing a start
signal to the equipment it controls while event #2 is affected by only
one of the sixteen logic test steps.

The probability that an individual sequencer would not respond to a valid
same train SI signal is 4 hours/16 hours = 2.5E-1.  The probability that
an individual sequencer would not respond to a valid opposite unit SI
signal is 1 hour/16 hours = 6.25E-2.

The equipment affected due to the failure of a sequencer was identified
from plant drawings.  The equipment listed below is specific to the 3A
sequencer.  The equipment lists would be similar for the other three

For event #1, the following equipment would not be automatically loaded
by the sequencer:

     Residual Heat Removal Pump 3A [BP:p]
     HHSI Pump 3A
     Intake Cooling Water Pumps 3A (1) and 3C (1) [BI:p]
     Emergency Containment Cooler Fan 3B and 3C [BK:fan]
     Component Cooling Water Pumps 3A (1) and 3C (1) [CC:p]
     Emergency Containment Filter Fans 3B and 3C {BK:fan]

     Note (1): The equipment identified may already be in operation and
               may not require manual action to start.

TEXT                                                         PAGE 8 OF 18

For events #3 and #4 (LOCA w/HHCP < 13 sec; LOCA w/HHCP > 13 sec),
Containment Spray Pump 3A would be affected in addition to the equipment
identified above for event #1.

For event #2 (LOCA other Unit), only the 3A HHSI Pump would not be
automatically started.

It should be noted that one of the initiating signals for Auxiliary
Feedwater (AFW) system [BA:p] is bus stripping, which is controlled by
the sequencer.  No credit is taken, however, for bus stripping in the
accident analyses for initiating AFW.  AFW is also initiated on low-low
steam generator level, SI, manual initiation and trip of all Main
Feedwater pumps [SJ:p].

Using the above information, the defect in the sequencer test logic
represents a potential concern for events where SI is required for
mitigation and no LOOP is experienced.

CS Pump Autostart Software Error
Using the Turkey Point baseline Probabilistic Safety Assessment model,
the probability of dual train failure of the CS system if called on to
operate has been estimated to be approximately 2.6E-3.  This estimate
reflects CS system and support system component failure probabilities not
including either of the software errors reported here.

The failure to automatically start a CS pump due to this software error
can only occur under a very remote set of circumstances.  The 60 ms
window is on the same order as the tolerance on relay pick-up times and
the sequencer processing and timing tolerances.  Even with sophisticated
timing equipment, it is unlikely that the failure mode could be
demonstrated repeatedly.  The probability of receipt of a HHCP signal
during a 60 ms window of vulnerability compared to the range of timing
conditions for which the sequencer is designed is considerably smaller
than the overall system reliability identified above.  If it is assumed
that HHCP can occur at any time within approximately two minutes after
the SI signal (the earliest time at which SI is postulated to be reset),
then the probability of the evaluated condition occurring on one train

     0.060 sec/(2 min x 60 sec/min) = 5.0E-4

The estimate of the probability of a CS pump not starting automatically
in a LOCA or LOOP/LOCA due to the reported software error is therefore
approximately a factor of five below the estimated probability of both CS
trains failing during a design basis event.

TEXT                                                         PAGE 9 OF 18

The probability of the software error affecting both trains is
considerably lower, since it would require: 1) the initiating SI signals
to be at the sequencer inputs within 60 ms of each other; 2) the two
trains of HHCP both occurring within the 60 ms window of vulnerability;
3) the sequencer input processing times to be identical; and 4) the
timing of the two sequencers in synchronization.  The difference in the
cumulative delay time for relay actuations on the two trains of ESFAS and
differences in sequencer processing, in all likelihood would be
sufficient to preclude the condition on both trains.  This conclusion is
supported by a review of previous Integrated Safeguards Test data.  The
difference between the train A and B CS pump recorded start times during
a simulated LOOP/LOCA has been between 90 and 500 ms.  Since some timing
differences between the trains can be expected, and timing differences
greater than 60 ms have been recorded during previous safeguards tests,
the probability that the specific error could affect both trains of
Containment Spray is therefore considerably less than the single train

Effect on Analyzed Accidents

A review of the Turkey Point UFSAR Chapter 14 Accident Analyses was
performed to determine which accidents would be potentially affected by
the sequencer test software logic defect.  This review identified 7 of
the 22 accidents which may be affected.  Two of the seven, "Loss of
External Load" and "Loss of A.C. Power" were determined to be dependent
on the sequencer but not affected, since the inhibited sequencer failure
mode applies to loss of coolant accident (LOCA) scenarios only, i.e., no

The five accidents both requiring SI, and affected by the sequencer test
software logic defect, are the following:

     1.   Large Break Loss-of-Coolant Accident (LBLOCA)
     2.   Small Break LOCA (SBLOCA)
     3.   Rupture of a Steam Pipe (Main Steam Line Break, or MSLB)
     4.   Steam Generator Tube Rupture (SGTR)
     5.   Rupture of a Control Rod Mechanism Housing

The effects of the sequencer test logic defect will be discussed below
for each of the five accidents.  In each case, the transient is described
and equipment necessary for mitigation of accidents is identified.  Each
transient is then evaluated assuming all four sequencers fail to operate
properly.  Credit is assumed for operator action to start HHSI pumps as
well as other ESF equipment within 10 minutes as described below.


A LOCA would result from a rupture of the Reactor Coolant System (RCS) or
any line connected to that system up to the first closed valve.  For a
postulated LBLOCA, a reactor trip is initiated by pressurizer low
pressure (1790 psig) while the SI signal is actuated by, pressurizer low
pressure at 1636 psig.  The consequences of the LBLOCA are limited in two

     1.   Reactor trip and borated water injection supplement void
          formation in causing rapid reduction of nuclear power to a
          residual level corresponding to fission product decay.

     2.   Injection of borated water ensures sufficient flooding of the
          core to prevent excessive temperatures and provide long term

TEXT                                                        PAGE 10 OF 18

The reactor is designed to withstand the thermal effects caused by a
LBLOCA including the double ended severance of the largest RCS pipe.  The
reactor core and internals, together with the Emergency Core Cooling
System (ECCS), are designed so that the reactor can be safely shutdown
and the essential heat transfer geometry of the core will be preserved
following an accident.

The LBLOCA analysis presented in Section 14.3 of the UFSAR assumes that 2
of 4 HHSI pumps and 1 of 2 RHR pumps are automatically actuated during
the accident.  If all four sequencers were inoperable because of the
simultaneous presence of the test logic defect, SI actuation would not
occur automatically.

The LBLOCA is a design basis event whose probability of occurrence is
extremely small.  A LBLOCA is considered to be a break with a total
cross-sectional area equal or greater than 1.0 ft**2.

LBLOCA sensitivity studies, performed in 1988 to assess the impact of
delaying SI, indicate that the maximum permissible SI delay is about 1
minute in order not to exceed the Peak Clad Temperature criteria of 10
CFR 50.46, and about 5 minutes to avoid exceeding fuel melt temperature,
for a generic Westinghouse four-loop PWR.  As a result of the test logic
defect, Turkey Point tested operator reaction times to manually start SI
in the absence of an automatic start (described below under MITIGATION OF
SEQUENCER FAILURE MODES).  The maximum time did not exceed 4 minutes.
This information was provided to Westinghouse, who then determined that
if SI is delayed 3 minutes and 15 seconds, the peak clad temperature for
the hot rod will not exceed 1922 degrees Fahrenheit.  If a conservative
adiabatic heat up rate of six degrees per second is assumed for the fuel,
SI may be delayed until four minutes into the LOCA without exceeding 10
CFR 50.46 PCT criteria.  Therefore,if reasonable operator action is
credited, no core damage would be expected.

     Containment Response to a LBLOCA

A LBLOCA results in a significant mass and energy release into
containment that results in pressurization of the containment structure.
The UFSAR indicates that the pressurization event is limited by the size
of containment, by containment heat sinks, and by the operation of
containment cooling equipment (containment sprays and emergency
containment coolers).

The containment analysis for the LBLOCA was assessed using better
estimate techniques in 1989 by Westinghouse.  This analysis showed that
peak containment pressure for a Double Ended Pump Suction (DEPS) to be on
the order of 42 to 45 psig.  Using the mass and energy release values
developed for the design basis reconstitution work, Westinghouse
re-performed the Turkey Point containment analysis assuming no operation
of the containment spray pumps or the emergency containment coolers, for
ten minutes.  This reanalysis shows that the peak pressure of the DEPS
LOCA to be approximately 44.3 psig.  Accordingly, since this peak
pressure is less than the design pressure of 55 psig and less than the
originally analyzed peak pressure of 49.9 psig, the results are
acceptable.  The ultimate strength of the Turkey Point containments is
estimated to be approximately 140 psig based on the Individual Plant
Examination (IPE) analysis work.

TEXT                                                        PAGE 11 OF 18

     Dose Consequences for a LBLOCA

The UFSAR contains an offsite dose evaluation that assumes a total core
release (100% noble gas, 50% halogens) occurring at time t = 0 with
results that remain within 10 CFR Part 100 guidelines.  The event under
review, however, is different than that evaluated in the UFSAR in that
engineered safety features are assumed to be delayed.  Using knowledge
learned from observation of accident phenomena and advanced light water
reactor development programs, it has been concluded that an instantaneous
core melt and release of fission products to containment is not credible.
Rather, significant release to the containment would not be expected to
occur during the first ten minutes of an accident.  During this time,
credit is taken for operator action to start SI, containment sprays, etc.
Manual actuation of the containment sprays and emergency filters would
provide for fission product cleanup within containment.  While a
calculation has not been performed, it is expected that the offsite dose
consequences for this event will not exceed those stated in the UFSAR.
Operation of sprays and filters will provide radioactive material cleanup
prior to any significant fission product release from the containment.


SBLOCAs are slow transients which take longer to initiate SI and
therefore are less sensitive to delays in the actuation of the HHSI
pumps.  Containment response and dose consequences for the SBLOCA event
are bounded by LBLOCA discussions above.


The UFSAR analyzes two separate steam line break events; opening a relief
or safety valve, and main steam piping failure.  The piping failure
bounds the opening of the relief or safety valve.  Since the sequencer
issue is only a concern for the offsite power available case, only a main
steam piping failure with offsite power available will be addressed.  The
most limiting cooldown event occurs at zero power with no decay heat.  As
indicated in the UFSAR, credit is taken for a single HHSI pump to provide
borated water to return the core to a subcritical state.

Westinghouse re-performed the limiting MSLB accident with offsite power
available assuming SI was not available for ten minutes.  The results of
this analysis indicate that the event can be accommodated without SI for
ten minutes with acceptable results.

     Containment Response to an MSLB

A Main Steam Line Break inside containment also results in a containment
pressurization transient.  This event was rerun by Westinghouse assuming
no active containment pressure mitigating features (i.e. no containment
sprays or containment coolers).  Assuming no safeguards actuation, peak
containment pressure for the MSLB was 48.8 psig occurring approximately
300 seconds (5 minutes) into the transient.  This is within the
containment design pressure of 55 psig and is therefore acceptable.

TEXT                                                        PAGE 12 OF 18


The event examined in the UFSAR is a complete tube break adjacent to the
tube sheet.  Each steam generator tube has a nominal diameter of 0.875
inches with a wall thickness of 0.050 inches.  Accordingly, the cross-
sectional break area of a double ended tube rupture is less than 1.0
square inches.  This small break area shows that this event is bounded by
the SBLOCA in terms of assessing the potential for core damage resulting
from this event, and that dose releases for this event will not increase
as a result of delayed SI.


The event examined in the UFSAR is a failure of a control rod mechanism
pressure housing such that RCS pressure would eject the control rod and
drive shaft to a fully withdrawn position.  The consequence of this
mechanical failure is a rapid positive reactivity insertion together with
an adverse core power distribution.  The reactivity transient is
terminated by the Doppler reactivity effects of the increased fuel
temperature, and by subsequent reactor trip before conditions are reached
that can result in fuel melt.

Actions are included in the Emergency Operating Procedures (EOPs) to
address a SBLOCA that could be caused by a failed control rod mechanism
pressure  housing.  Accident consequences of a SBLOCA in the reactor
vessel upper head are bounded by the design-basis SBLOCA in the cold leg.

Summary of Potential Accident Consequences

Of the five UFSAR accidents affected, four are bounded by the LBLOCA.
Consequences of a LBLOCA are acceptable if operator action to start ESF
equipment takes place within four minutes of the start of the accident.
The consequences of a MSLB are acceptable without operator action for ten
minutes, since containment pressure peaks, below the design pressure,
five minutes into the accident.


Because the presence of an SI signal during sequencer testing (automatic
or manual mode) may render the sequencer inoperative, the dependence on
SI was the primary consideration for determining the five affected
accidents.  For each of the affected accidents, the EOPs were reviewed to
determine what mitigating actions would be taken by the operator.  The
effectiveness of the mitigating actions was also assessed based on its
sequence within the procedures.

Upon initiation of any of the five affected accidents discussed above,
the reactor would trip placing the operators in procedure 3/4-EOP-E-0,
"Reactor Trip or Safety Injection." At Step 4 in EOP-E-0, the operator
verifies whether SI is actuated or is required.  If an SI is required,
the operator verifies that HHSI and RHR pumps have started, or he is
required to manually start these pumps in Step 8.  These two steps are
part of the immediate actions to be taken by an operator following a
reactor trip.

TEXT                                                        PAGE 13 OF 18

In addition, the foldout pages for EOP-E-0 contains specific reactor trip
and SI actuation criteria which require operators to start the HHSI
pumps.  Therefore FPL concludes that for these five accidents, there is a
high probability that timely mitigating actions would have been taken by
the operators to activate safeguards equipment even if the sequencer had

To assess the operators' ability to accommodate sequencer test software
logic defects, the Turkey Point Training Department constructed three
different scenarios involving design basis accidents with failed
sequencers.  The failure mode modeled was a failure of the sequencer to
load safeguards equipment.  These scenario runs were completed on
November 5, 1994.  The three scenarios were:

     1.   A LOOP/LBLOCA with Unit 3 sequencers failed.

     2.   A LBLOCA with no LOOP, with Unit 3 sequencers failed.

     3.   A SBLOCA with no LOOP, with Unit 3 sequencers failed, Unit 4
          HHSI pump breakers racked out, and the Unit 3 HHSI pump control
          switches in PULL TO LOCK on the Unit 4 control board.

Six control room crews ran each of the three scenarios, for a total of 18
simulator exercises.  The Training Department was primarily interested in
determining how long it took the control room crew to successfully
energize all available safeguards equipment.  A summary of the control
room crew response times follows:

                              INITIATION (IN MEN:SEC)
                         LOOP/LOCA           LBLOCA         SBLOCA
                         SCENARIO            SCENARIO       SCENARIO

          A                2:40                2:30           2:45
          B                2:00                2:10           1.40
          C                2:50                1:30           1:30
          D                8:00                1:30           1:55
          E                4:40                3:15           1:05
          F                2:50                1:32           1:20

The simulator training coordinator stated that the longest time required
to initiate SI flow was during Crew D's 8 minute LOOP/LOCA scenario; it
took them approximately 4 minutes.  However, the sequencer defect is not
present for LOOP scenarios.  The longest non-LOOP response time was 3
minutes and 15 seconds.  An assumed operator response time of 10 minutes
is therefore conservative.

In addition to the scenario exercises described above, a review of
earlier observations of operating crews in simulator training during July
and August 1994 was made.  These observations illustrated that it took
each crew 4 to 5 minutes from event initiation to complete alignment of
the required safeguards equipment associated with a full sequencer

TEXT                                                        PAGE 14 OF 18

Operator verification of SI, and HHSI pump flow, is performed within the
immediate action steps (Steps 4 and 8 respectively) of EOP-E-0.  The
first 14 steps are memorized by the control room crew.  In addition,
immediate action steps are required to be re-verified by the operators.
Therefore FPL concludes that the control room crew would be successful in
timely initiation of HHSI pump flow in the event of a sequencer


A probabilistic safety assessment was performed to estimate the safety
impact of inhibited emergency sequencer operation due to a logic error in
the software associated with the test feature.  The assessment is based
on the Turkey Point IPE Submittal and subsequent updates, and includes
the effect of the failure of all four sequencers.  The recovery actions
are added to the model for different scenarios, e.g., recovery for LBLOCA
vs. SBLOCA.  These operator actions are calculated based on the time
available to do the actions (NUREG/CR-4550, Vol. 3, Rev. 1, Part1), and
the time it takes the operators to perform the actions obtained from a
review of 3/4-EOPs-0 and from simulator scenario runs.

The probabalistic safety assessment determined that the estimated change
in the Core Damage Frequency (CDF) under the above conditions, with all
four sequencers inoperable, is 6.3E-6/yr.  However, all four sequencers
were not inoperable at all times.  Each sequencer is inoperable during 5
of the 16 tests.  In order for all sequencers to fail simultaneously, all
sequencers would have to be in an affected test.  This would happen most
often if all four sequencer test cycles were synchronized.  Even if all
four sequencers were synchronized on the same test cycle, the sequencers
would all be inoperable during only 5 of the 16 tests.  Therefore, all
four sequencers would be inoperable approximately one-third of the time.
This results in an estimated change in CDF of 2.1E-6/yr.  This change in
core damage frequency increases the baseline CDF by 3.2%.  The PRA
calculation considers an average probability over a one year period.

The 3.2% increase in the CDF is a conservative estimate for this
situation.  This increase in CDF is not safety significant, based on the
acceptance criteria stipulated in the draft EPRI PSA Application Guide.

The estimated risk impact of loss of sequencers for LBLOCAs is relatively
low due to the low initiating event frequency of LBLOCAs, and recovery
actions described in the early steps of the EOP E-0 for reactor trip and
SI.  Although SBLOCAs have a higher initiating event frequency the risk
is relatively low because the operator has more time available to perform
recovery actions.

TEXT                                                        PAGE 15 OF 18

An estimate of the potential risk impact of the failure of the CS pumps
to automatically start was performed.  The scenario is assumed to occur
for a certain size LOCA or MSLB such that the HHCP signal is generated at
the 12.9 to 13.0 second window during which the sequencers may not
actuate CS pumps automatically.  A further assumption is that failure of
all containment spray with a medium LOCA leads directly to core damage.
The core damage frequency increase is thus estimated to be:

     CDF   =   (frequency of event [medium and small LOCAs, MSLB]) times
               (probability of "right size" break to cause the event)
               times (probability of failure of manual starting of CS

           =   (1.0E-4 + 1.0E-3 + 1.0E-4) x (5.0E-4) x (6.0E-3)

           =   3.6 E-9 / year

Note that the frequency of the event is conservatively estimated to be
that of the medium LOCA (6-13.5 inches), the small LOCA (2-6 inches) or a
MSLB.  Since a specifically-timed LOOP would be required for either the
small LOCA or the MSLB to be of concern, the CDF is actually lower.

A estimated increase in the CDF of 3.6E-9/yr is insignificant compared to
the baseline CDF of 6.63E-5/yr.


The periodic inoperability of all four sequencers, as described above,
has existed since the sequencers were installed during the dual unit
outage in 1990/1991.  The sequencers were accepted as operational in
September and October, 1991, for Units 3 and 4, respectively.  From early
December, 1991, until November, 1992 (Unit 3) and May, 1993 (Unit 4) the
sequencers' Test Selector switches were in OFF except for monthly manual
tests, as described in LER 251/91-007.

Since then, there have been four challenges to the bus sequencers
(between the two units).  LER 251/92-004 reported an inadvertent Safety
Injection on Unit 4; all plant equipment responded as designed, including
the Unit 3 HHSI pumps.  LERs 250/92-009 and 250/92-013 reported a LOOP
(due to hurricane Andrew), and an inadvertent 3A bus stripping.  In these
three instances the sequencers' Test Selector switches were not in AUTO,
and they performed as designed.

LER 250/94-002 reported an inadvertent ESF actuation on Unit 3, in which
all equipment responded as design, except the 4A HHSI pump.  At that time
the failure of the 4A HHSI pump was attributed to an intermittent
failure, which could not be reproduced.  As a result of the discovery of
the defect reported herein, that earlier event can now be reproduced at
will on the sequencer simulator.  FPL believes that the 4A HHSI pump
failed to start because of the same defect that caused the 3A HHSI pump
failure to start, reported in this LER.

Since there have been no actual events requiring Engineered Safety
Features actuation to protect the plant, the health and safety of the
public has not been affected by the periodic inoperability of the

This event is reportable under the requirements of 10 CFR 50.73
(a)(2)(i)(B), (a)(ii)(A), (a)(ii)(B), (a)(v), (a)(vii), and 10 CFR 21.

TEXT                                                        PAGE 16 OF 18

Regarding the second software error involving the CS pump autostart, FPL
has concluded that the CS system remains OPERABLE because, in the highly
unlikely event that the condition were to occur, simple operator action
to start the CS pumps, in accordance with the plant's emergency operating
procedures, would ensure compliance with the system specified functions.
The ability to manually start the CS pumps as much as ten minutes into
the event and maintain required cooling is supported by analysis,
procedures, and training.  In addition the safety significance of the
evaluated condition is extremely low because the probability of the
evaluated condition is lower than the probability of a common mode
failure of both CS trains, as discussed earlier under Possible Accident
Consequences for Sequencer Failure Modes.  In any case, the contribution
to CDF of this software error is negligible.


1.   The Test Selector switches on all four sequencers were placed in
     OFF.  Tags have been hung on each switch to require specific
     permission from the Nuclear Plant Supervisor to change the position
     of the switch.  With the sequencer test mode switch in the OFF
     position, the automatic test logic is disabled.  The sequencer is
     fully functional and will respond properly to input signals.  The
     automatic test function is not a requirement for periodic
     surveillance of the sequencer.

2.   With the Test Selector switch in OFF, additional visual inspections
     are being performed on a eight hour basis as described below:

     a.   The local reflash annunciators points are verified not in

     b.   The I/O power, PLC Power, and ANN Power switches are verified
          in the ON position and the Processor Power white indicating
          light is verified illuminated.

     c.   The Test Selector switch is verified in the OFF position; the
          Stripping Clearing Test Selector and Sequencing Mode Test
          Selector Switches are verified in the OFF position.

     d.   The 2 green test reset indicating lights and the sequencing
          reset green indicating lights are verified illuminated.

     e.   The other indicating lights are verified not to be illuminated
          (except the ground fault indicating lights are supposed to be
          dimly lit).

     f.   Every 24 hours, the sequencer door is opened, the Processor
          Indicator LED is verified to be a solid green and the 9
          indicator I/O cards "ACTIVE" LED are verified to be a solid

3.   A detailed review of the original Validation and Verification
     process was performed; it has been concluded that an oversight
     occurred because not all sequencer functions were validated during
     all modes of automatic and manual testing.  The existing
     verification and validation sufficiently covers the sequencer safety
     functions if the Test Selector switch remains OFF.

TEXT                                                        PAGE 17 OF 18

4.   Functional testing on the sequencer simulator of design basis inputs
     has been repeated with the Test Selector switch OFF, with acceptable

5.   A safety evaluation has been issued demonstrating sequencer
     operability with the test selector switch in the OFF position.  This
     safety evaluation was approved by the Plant Nuclear Safety Committee
     on November 4, 1994.

6.   Independent consultants were retained to perform an assessment of
     the existing sequencer design, software design and V&V.  This
     "Independent Assessment Team" (IAT) concluded that operation of the
     sequencers with the Test Selector switch in OFF represented a safe
     condition and that FPL's evaluation of the condition was

     The second phase of the IAT's assignment was to provide a detailed
     review of the software documentation.  Some drawing discrepancies
     were identified and have been evaluated.  In general the
     discrepancies dealt with the inclusion of additional information on
     the logic diagrams not reflected in the ladder diagrams, to aid in
     understanding the logic diagrams.  One other software error was
     identified involving autostart of the CS pumps, and has been
     discussed earlier in the LER.  The drawing discrepancies will be
     corrected when the software is modified (see Corrective Action #9

     The IAT confirmed that the V&V was not comprehensive enough to test
     certain aspects of the logic.  "The plan was weak in that it relied
     almost completely on testing as the V&V methodology.  More emphasis
     on the analysis of the requirements and design would have increased
     the likelihood of discovering the design flaw." A revision to the
     V&V documentation will be made coincident with the design
     modifications described on Corrective Action #9 below.

7.   The original software vendor, United Controls, Inc. has been
     notified of this defect and its significance.

8.   In order to eliminate issues related to the use of one-of-a-kind or
     first-of-a-kind equipment, FPL implemented Nuclear Policy NP-905,
     Equipment Selection, in October of 1991.  This policy states in part
     that, "FPL's nuclear engineering department shall select only
     specific models of equipment with proven records of reliable
     performance for use in FPL nuclear facilities.  Verification of the
     equipment reliability must be established through contact with
     NPRDS, nuclear station managers, or other appropriate sources.  If
     no prior operating experience is available, appropriate prototype
     testing, under equivalent plant operating conditions, must be
     undertaken to establish its reliability before it is placed in
     service at FPL nuclear facilities." The Engineering Quality
     Instructions contain the Nuclear Policy requirements for design

9.   Design modifications to eliminate the software logic problems will
     be implemented during the next refueling outages of each unit.

10.  Other safety-related process computer suppliers were notified of the
     event on November 14, 1994.  These suppliers responded that similar
     software errors do not exist in other safety-related process

TEXT                                                        PAGE 18 OF 18

11.  An FPL Nuclear Engineering standard will be developed on the use of
     PLCs, prior to the procurement of any additional PLC-based

12.  Manual testing of the sequencers was resumed on January 11, 1995.


EIIS Codes are shown in the format [EIIS SYSTEM: IEEE component function
identifier, second component function identifier (if appropriate)].

The Programmable Logic Controllers used in the sequencers are made by
Allen-Bradley; the sequencers are assembled by United Controls, Inc.
(UCI).  According to UCI, Florida Power & Light Company is the only
utility to which UCI supplied this sequencer.

ATTACHMENT TO 9502220392                                      PAGE 1 OF 1

FPL                                          FEB 09 1995
                                             10 CFR 50.73

U. S. Nuclear Regulatory Commission
Attn:  Document Control Desk
Washington, D. C.  20555


Re:  Turkey Point Units 3 and 4
     Docket No. 50-250, 50-251
     Reportable Event: 94-005-01
     Design Defect in Safeguards Bus Sequencer Logic Timing
     Places Both Units Outside the Design Basis

The attached revised Licensee Event Report 250/94-005-01 is being
provided in accordance with 10 CFR 50.73 (a)(2)(ii), (a)(2)(v),
(a)(2)(vii), AND 10 CFR 21.

If there are any questions, please contact us.

Very truly yours,

T. F. Plunkett
Vice President
Turkey Point Plant



cc:  Stewart D. Ebneter, Regional Administrator, Region II,
     Thomas P. Johnson, Senior Resident Inspector, Turkey Point Plant,

an FPL Group company


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