LER-1979-067, /01T-0 on 790628:short Circuit Caused Loss of Essential Bus Y4 Sypplying Power to Safety Feature Actuation Sys.Blown Inverter Fuse Was Replaced & Y4 Bus Returned to Normal Supply |
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U. S. NUCLE AR REGUL ATORY COM,'.ilSSION NRC FORM 3GG [7 77)
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[ At 0157 hours0.00182 days <br />0.0436 hours <br />2.595899e-4 weeks <br />5.97385e-5 months <br /> on June 28, 1979, an accidental short circuit causea the loss of essen-)
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tial bus Y4 which supplies power to Safety Features Actuation dystem (STAS) Channel 4 4 fo 3
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the health and safety of the public or statiog lol7ll fic ation 3.4.1.
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- personnel, DH flow was not needed due to the low decay heat level.
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DH 11 was reopened and the 2500J The blown inverter fuse was replaced and the j gpm DH flow re-established by 0215 hours0.00249 days <br />0.0597 hours <br />3.554894e-4 weeks <br />8.18075e-5 months <br />.
[ pgl l Y4 bus returaed to its normal supply.
Facility Change Request 79-273 was prepared tol 11 [.[ [ he l ;, prevent accidental shOrt circuitin:: of the 12 voit AC sources.
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TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION U'iIT ONE SUPPLEMENTAL INFOR't\\ TION FOR LER NP-32-79-09 DATE OF EVENT:
June 28, 1979 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE: Loss of Safety ' Features Actuation System (SFAS)
Channel 4 due to loss o1 Y4 Conditions Prior to Occurrence: The unit was in Mode 5, with Power (MWT) = 0, and Load (Gross MWE) = 0.
, Description of Occurrence: At 0157 hours0.00182 days <br />0.0436 hours <br />2.595899e-4 weeks <br />5.97385e-5 months <br /> on June 28, 1979, while conducting surveil-lance testing on the Reactor Protection System (RPS) Channel 4, an alligator clip slipped off a terminal screw and shorted across another terminal.
The 120 volt AC power supply to RPS Channel 4, Y4 was lost causing a loss of power to the SFAS Chan-ne l 4.
The SFAS Channel 4 bistables tripped as designed upon a loss of power.
The trip of one SFAS channel does not actuate any SFAS incident level but the trip of SFAS Channel 4 does actuate the bistable which closed the Decay Heat (DH) Normal Cooldown Isolation Valve DH 11.
The closure of DH 11 isolated the DH System and since tiiet e were av Keatuut Cvulant Pumps in operation, placed the unit in violation of Technical Specification 3.4.1, which requires in Moda 5 at least one Reactor Coolant Pump or Decay Heat Pump be in op era t io n. The Decsy Heat Pump uas manually shutdoun before all DH flow was lost to pro te c t the pump.
Designation of Annarent Cause of Occurrence: The shorting of terminals with an alli-gator clip was due to not having large enouSh termination screws to properly retain an alligator clip. However, the loss of Essential Instrumentation Panel Y4 and sub-sequent trip of SFAS Channel 4 and RPS Channel 4 can be attributed to a characteris-tic of inverter YV4, which causes its fuses to blow on a short circuit.
Analysis of Occurrence:
There was no danger to the health and safety of the public or to station personnel.
Since decay heat generation at the time of the occurrence was low, the flow was not required for decay heat removal. The RPS and SFAS channels fail to the actuated (safe) position upon a loss of power and were not rendered inop-erable by the loss of power.
The three remaining SFAS channels were operable.
Corrective Action
Panel Y4 was supplied by its alternate source YBR.
SFAS and RPS Channels 4 were re-energized and reset.
Operations personnel then reopened valve DH 11, restarted Decay Heat Pump 1-2 and re-established greater than 2800 gpm flow to Reac tor Coolant Sys ten by 0215 hours0.00249 days <br />0.0597 hours <br />3.554894e-4 weeks <br />8.18075e-5 months <br />, June 28, 1979. Under Maintenance Work Order LER #79-067
TOLEDO EDISON COMPANY DAVIS-BESSE Ml' CLEAR P0;ER STATION UNIT ONE PAGE 2 SUPPLEMENTAL INFOR"\\ TION FOR LER NP-32-79-09 79-2405, the blown fuse was replaced in YV4.
At 1430 hours0.0166 days <br />0.397 hours <br />0.00236 weeks <br />5.44115e-4 months <br /> on June 28, 1979, YV4 was returned to service and operations personnel re-energized panel Y4 to normal.
Previoas invastigation into the loss of an inverter by Power Engineering and the ven-dor have deteruined it would be more detrinental to modify the inverter to prevent recurrence than to leave the inverter in its initial state.
Facility Change Request 79-273 was prepared to prevent shorting of the 120 volt AC sources to the RPS cabi-nets by nodifying the terninals.
Failure Data:
Previous f ailures fer loss of essential 120 volt aC power supply have been reported in Licensee Event Reports NP-33-77-05, NP-33-77-10, NP-33-77-14,
' and NP-33-79-13.
LER #79-067 s
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| 05000346/LER-1979-001-03, /03L-0 on 790102:monthly Functional Test Not Performed on Reactor Protection Sys Channel 2 within Allowable Time.Caused by Breakdown in Communications Between Testing Personnel & Test Coordinator | /03L-0 on 790102:monthly Functional Test Not Performed on Reactor Protection Sys Channel 2 within Allowable Time.Caused by Breakdown in Communications Between Testing Personnel & Test Coordinator | | | 05000346/LER-1979-001, Forwards LER 79-001/03L-0 | Forwards LER 79-001/03L-0 | | | 05000346/LER-1979-002-03, /03L-1 on 790102:main Steam Valves 106 & 106A Failed to Open,Resulting in Auxiliary Feed Pump Afp 1-1 Being Taken Out of Operation.Caused by Dirt Buildup on Valve Stems as Result of New Const | /03L-1 on 790102:main Steam Valves 106 & 106A Failed to Open,Resulting in Auxiliary Feed Pump Afp 1-1 Being Taken Out of Operation.Caused by Dirt Buildup on Valve Stems as Result of New Const | | | 05000346/LER-1979-002, Forwards LER 79-002/03L-1 | Forwards LER 79-002/03L-1 | | | 05000346/LER-1979-003-03, /03L-0 on 790104:control Room Emergency Ventilation Sys Damper HV5311E Inoperable.Caused by Leaking Pneumatic Operator.New Operator Installed.Damper Operated & Tested for Response Time & Declared Operable | /03L-0 on 790104:control Room Emergency Ventilation Sys Damper HV5311E Inoperable.Caused by Leaking Pneumatic Operator.New Operator Installed.Damper Operated & Tested for Response Time & Declared Operable | | | 05000346/LER-1979-003, Forwards LER 79-003/03L-0 | Forwards LER 79-003/03L-0 | | | 05000346/LER-1979-004, Forwards LER 79-004/03L-0 | Forwards LER 79-004/03L-0 | | | 05000346/LER-1979-004-03, /03L-0 on 790105:failure to Post Guards at Entrance to Containment During Periods of Free Access. Caused by Personnel Error.Special Order 84 Revised to Require Posting of Guards | /03L-0 on 790105:failure to Post Guards at Entrance to Containment During Periods of Free Access. Caused by Personnel Error.Special Order 84 Revised to Require Posting of Guards | | | 05000346/LER-1979-005, Forwards LER 79-005/03L-0 | Forwards LER 79-005/03L-0 | | | 05000346/LER-1979-005-03, /03L-0 on 790106:during Surveillance Testing, Borated Water Storage Tank Level Bistable Was Tripped;Valves DH9A Opened & DH7A Closed.Caused by Component Failure of Output Relay K51A & Instrument Drift | /03L-0 on 790106:during Surveillance Testing, Borated Water Storage Tank Level Bistable Was Tripped;Valves DH9A Opened & DH7A Closed.Caused by Component Failure of Output Relay K51A & Instrument Drift | | | 05000346/LER-1979-006-03, /03L-0:on 790105,reviewer Noted 781228 Record of Continuous Alarm at Contact Data Record Point F018.Panel C4705 Not Reset.Caused by Failure of Indicator Lights on Panel C4705.Panel Reset,Clearing F018.Surveillance Modified | /03L-0:on 790105,reviewer Noted 781228 Record of Continuous Alarm at Contact Data Record Point F018.Panel C4705 Not Reset.Caused by Failure of Indicator Lights on Panel C4705.Panel Reset,Clearing F018.Surveillance Modified | | | 05000346/LER-1979-006, Forwards LER 79-006/03L-0 | Forwards LER 79-006/03L-0 | | | 05000346/LER-1979-007-03, /03L-0 on 790110:during Performance of Surveillance Test,Channel 2 of Containment Hydrogen Analyzer Was Found Inoperable.Caused by Defective Zener Diode in Millivolt Converter | /03L-0 on 790110:during Performance of Surveillance Test,Channel 2 of Containment Hydrogen Analyzer Was Found Inoperable.Caused by Defective Zener Diode in Millivolt Converter | | | 05000346/LER-1979-007, Forwards LER 79-007/03L-0 | Forwards LER 79-007/03L-0 | | | 05000346/LER-1979-008, Forwards LER 79-008/03L-0 | Forwards LER 79-008/03L-0 | | | 05000346/LER-1979-008-03, /03L-0 on 790109:during Surveillance Testing, Containment Recirculation Fan 1-1 Failed to Run.Cause Attributed to Buildup of non-conductive Film on Auxiliary Controller Contacts | /03L-0 on 790109:during Surveillance Testing, Containment Recirculation Fan 1-1 Failed to Run.Cause Attributed to Buildup of non-conductive Film on Auxiliary Controller Contacts | | | 05000346/LER-1979-009, Forwards LER 79-009/03L-0 | Forwards LER 79-009/03L-0 | | | 05000346/LER-1979-009-03, /03L-0:on 790112,power to Vital Bus Y2 Lost. False Integrated Control Sys Signal Resulted in Reactor & Full Steam & Feedwater Rupture Control Sys Trip.Caused by Blown 125 Volt DC Fuse to Inverter | /03L-0:on 790112,power to Vital Bus Y2 Lost. False Integrated Control Sys Signal Resulted in Reactor & Full Steam & Feedwater Rupture Control Sys Trip.Caused by Blown 125 Volt DC Fuse to Inverter | | | 05000346/LER-1979-010-03, /03L-0:on 790112,Sys 7 Data Logger Experienced Core Dump,Voiding Computer Memory Bank Which Rendered Remote Monitoring of Fire Detection Sys Inoperable & Placed Unit in Action Statement of Tech Spec 3.3.3.8.Cause Unknown | /03L-0:on 790112,Sys 7 Data Logger Experienced Core Dump,Voiding Computer Memory Bank Which Rendered Remote Monitoring of Fire Detection Sys Inoperable & Placed Unit in Action Statement of Tech Spec 3.3.3.8.Cause Unknown | | | 05000346/LER-1979-010, Forwards LER 79-010/03L-0 | Forwards LER 79-010/03L-0 | | | 05000346/LER-1979-011-03, /03L-0:on 790115,reactor Coolant Pump 1-2-2 Started W/Incorrect Breaker Alignment,Causing Low Voltage Relays to Trip Which de-energized Both 4.16 Kv Essential Buses C1 & D1.Caused by Personnel Error | /03L-0:on 790115,reactor Coolant Pump 1-2-2 Started W/Incorrect Breaker Alignment,Causing Low Voltage Relays to Trip Which de-energized Both 4.16 Kv Essential Buses C1 & D1.Caused by Personnel Error | | | 05000346/LER-1979-011, Forwards LER 79-011/03L-0 | Forwards LER 79-011/03L-0 | | | 05000346/LER-1979-012-03, /03L-0:on 790116,during Surveillance Testing,Heat Traced Line Temp Measurement Points Below 105 F Limit.Caused by Injection of Makeup (Flush) Water After Boron Injection at Temp Lower than 105 F.Tests Rerun Satisfactorily | /03L-0:on 790116,during Surveillance Testing,Heat Traced Line Temp Measurement Points Below 105 F Limit.Caused by Injection of Makeup (Flush) Water After Boron Injection at Temp Lower than 105 F.Tests Rerun Satisfactorily | | | 05000346/LER-1979-012, Forwards LER 79-012/03L-0 | Forwards LER 79-012/03L-0 | | | 05000346/LER-1979-013, Forwards LER 79-013/03L-0 | Forwards LER 79-013/03L-0 | | | 05000346/LER-1979-013-03, /03L-0:on 790116,when Makeup Pump 1 Started for Surveillance testing,1/2 Inch Nipple at Discharge of Attached Gear Driven Lube Oil Pump Failed,Resulting in Oil Spray Which Required Pump Shutdown | /03L-0:on 790116,when Makeup Pump 1 Started for Surveillance testing,1/2 Inch Nipple at Discharge of Attached Gear Driven Lube Oil Pump Failed,Resulting in Oil Spray Which Required Pump Shutdown | | | 05000346/LER-1979-014-03, /03L-0:on 790116,during Shutdown,Boric Acid Addition Tanks (Baat) Total Vol 3-1/3% Below Tech Spec 3.1.2.9 Requirements.Caused by Reduced Baat Vol After Completion of Required Testing Followed by RCS Boration | /03L-0:on 790116,during Shutdown,Boric Acid Addition Tanks (Baat) Total Vol 3-1/3% Below Tech Spec 3.1.2.9 Requirements.Caused by Reduced Baat Vol After Completion of Required Testing Followed by RCS Boration | | | 05000346/LER-1979-014, Forwards LER 79-014/03L-0 | Forwards LER 79-014/03L-0 | | | 05000346/LER-1979-015-03, /03L-0:on 790117,core Flood Tank 1-2 Isolation Valve CF1A Would Not Close by Remote Operation.Caused by Loose Set Screw.Cracked Pinion Gear & Associated Key Replaced Per Maint Work Order 78-2928 | /03L-0:on 790117,core Flood Tank 1-2 Isolation Valve CF1A Would Not Close by Remote Operation.Caused by Loose Set Screw.Cracked Pinion Gear & Associated Key Replaced Per Maint Work Order 78-2928 | | | 05000346/LER-1979-015, Forwards LER 79-015/03L-0 | Forwards LER 79-015/03L-0 | | | 05000346/LER-1979-016-03, /03L-0:on 790124,emergency Lock Failed Leak Rate Test While Unit in Mode 5.Caused by Loosening of Shaft Seal (Teflon Packing) Due to Routine Use of Escape Lock.Packing Will Be Replaced During Next Convenient Outage | /03L-0:on 790124,emergency Lock Failed Leak Rate Test While Unit in Mode 5.Caused by Loosening of Shaft Seal (Teflon Packing) Due to Routine Use of Escape Lock.Packing Will Be Replaced During Next Convenient Outage | | | 05000346/LER-1979-016, Forwards LER 79-016/03L-0 | Forwards LER 79-016/03L-0 | | | 05000346/LER-1979-017-03, /03L-0:on 790130,photoelectric Smoke Detector Ds 8605-E in Emergency Diesel Generator 1-1 Area Not Functional.Caused by Failure of Detector.New Detector Ordered & Fire Watch Patrol Established in Area | /03L-0:on 790130,photoelectric Smoke Detector Ds 8605-E in Emergency Diesel Generator 1-1 Area Not Functional.Caused by Failure of Detector.New Detector Ordered & Fire Watch Patrol Established in Area | | | 05000346/LER-1979-017, Forwards LER 79-017/03L-0 | Forwards LER 79-017/03L-0 | | | 05000346/LER-1979-018, Forwards LER 79-018/03L-0 | Forwards LER 79-018/03L-0 | | | 05000346/LER-1979-018-03, /03L-0:on 790130,valves SP17A2 & SP17B2 Lifted Below Setpoint Range & Declared Inoperable.Caused by Loose Spindle on Main Steam Line Code Safety Valve SP17A2.Valve SP17A2 Gagged & SP17B2 Tested Satisfactorily | /03L-0:on 790130,valves SP17A2 & SP17B2 Lifted Below Setpoint Range & Declared Inoperable.Caused by Loose Spindle on Main Steam Line Code Safety Valve SP17A2.Valve SP17A2 Gagged & SP17B2 Tested Satisfactorily | | | 05000346/LER-1979-019-03, /03L-0 on 790129:suction & Discharge Valves on Containment Spray Pump Were Closed.Caused by Personnel Error | /03L-0 on 790129:suction & Discharge Valves on Containment Spray Pump Were Closed.Caused by Personnel Error | | | 05000346/LER-1979-019, Forwards LER 79-019/03L-0 | Forwards LER 79-019/03L-0 | | | 05000346/LER-1979-020-03, /03L-0 on 790205:10 of 18 Main Steam Safety Valves Found Outside Setpoint Range.Believed Caused by Changing Ambient Conditions at Valve Locations.Valves Adjusted & Retested Satisfactorily | /03L-0 on 790205:10 of 18 Main Steam Safety Valves Found Outside Setpoint Range.Believed Caused by Changing Ambient Conditions at Valve Locations.Valves Adjusted & Retested Satisfactorily | | | 05000346/LER-1979-020, Forwards LER 79-020/03L-0 | Forwards LER 79-020/03L-0 | | | 05000346/LER-1979-021-03, /03L-0 on 790205:containment High Pressure Alarms Were Received & Safety Features Actuation Sys Channel 2 Erroneously Tripped.Cause Unknown.No Deficiencies Found from Surveillance Tests.Channel Returned to Operation | /03L-0 on 790205:containment High Pressure Alarms Were Received & Safety Features Actuation Sys Channel 2 Erroneously Tripped.Cause Unknown.No Deficiencies Found from Surveillance Tests.Channel Returned to Operation | | | 05000346/LER-1979-021, Forwards LER 79-021/03L-0 | Forwards LER 79-021/03L-0 | | | 05000346/LER-1979-022, Forwards LER 79-022/03L-0 | Forwards LER 79-022/03L-0 | | | 05000346/LER-1979-022-03, /03L-0 on 790208:diesel Fire Pump Battery Electrolyte Level in Four Cells Was Below Top of Cell Plates.Caused by Procedural Error.Levels Restored,Pump Declared Operable & Unit Removed from Action Statement | /03L-0 on 790208:diesel Fire Pump Battery Electrolyte Level in Four Cells Was Below Top of Cell Plates.Caused by Procedural Error.Levels Restored,Pump Declared Operable & Unit Removed from Action Statement | | | 05000346/LER-1979-023, Forwards LER 79-023/01T-0 | Forwards LER 79-023/01T-0 | | | 05000346/LER-1979-023-01, /01T-0 on 790228:Startup Transformer 01 Taken Out of Svc;Surveillance Tests Not Performed within One Hour, Contrary to Tech Spec Requirements.Caused by Personnel Error.Testing Completed as Soon as Error Realized | /01T-0 on 790228:Startup Transformer 01 Taken Out of Svc;Surveillance Tests Not Performed within One Hour, Contrary to Tech Spec Requirements.Caused by Personnel Error.Testing Completed as Soon as Error Realized | | | 05000346/LER-1979-024, Forwards LER 79-024/03L-0 | Forwards LER 79-024/03L-0 | | | 05000346/LER-1979-024-03, /03L-0 on 790214:fire Alarm Panel C4706 Signaled, Indicating Laundry Room Detector DS8630 as Source.Detector Declared Inoperable as No Cause for Signal Found.Cause of Event Undetermined.Possibly Due to Gases or Dust | /03L-0 on 790214:fire Alarm Panel C4706 Signaled, Indicating Laundry Room Detector DS8630 as Source.Detector Declared Inoperable as No Cause for Signal Found.Cause of Event Undetermined.Possibly Due to Gases or Dust | | | 05000346/LER-1979-025-03, /03L-0 on 790213:Ohio Edison Relay Testing Actuated Transfer Trip Receiving Relay & Tripped Switchyard Breakers.Caused by Failure of Util to Notify Toledo Edison Before Performing Relay Testing | /03L-0 on 790213:Ohio Edison Relay Testing Actuated Transfer Trip Receiving Relay & Tripped Switchyard Breakers.Caused by Failure of Util to Notify Toledo Edison Before Performing Relay Testing | | | 05000346/LER-1979-025, Forwards LER 79-025/03L-0 | Forwards LER 79-025/03L-0 | |
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