LER-1979-031, /03L-0 on 790219:two Computer Points Were Not Updating.Caused by Procedural Deficiency & Random Failures of Bailey Computer Sys.Surveillance Test Has Been Revised |
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NRC FORM 366 (7-77)
LICENSEE EVENT REPORT CONTROL BLOCK: l l
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8 60 61 DOCKET NUVBER 68 69 EVENT D ATE 74 75 REPORT DATE 80 3o R EVENT DESCRIPTION AND PROB ABLE CONSEQUENCC.S h o 2 i At 0215 hours0.00249 days <br />0.0597 hours <br />3.554894e-4 weeks <br />8.18075e-5 months <br /> and again at 1320 hours0.0153 days <br />0.367 hours <br />0.00218 weeks <br />5.0226e-4 months <br /> on 2/19/78, while in the Action Statement of l
Technical Specification 4.2.1 requiring manual calculation of Axial Power Imbalance }
,g,3, (AxPI), it was noted that two of the computer points being used in the calculation, l
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l due to the process computer alarm being inoperable, were not updating. An alternate loIsI o 6 l procedure for AxPI calculation was then performed. There was no danger to the health A review of the data indicated that l
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the AxPI did not exceed Technical Specification limits.
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40 41 42 43 44 47 33 34 J5 CAUSE DESCRIPTION AND CORRECTIVE ACTIONS h l The apparent cause of the occurrence was a procedural deficiency and a random f ailure 1 i
o I of the Bailey Computer System. A modification to Surveillance Test ST 5020.01 has l
3 been written to caution operators that when computer group 38 f ails to update, there l i
l is a possibility that computer points C927 and C928 will also be inoperable.
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DVR 79-041 NAVE OF PREPARER
TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-33-79-35
'DATE OF EVENT: February 19, 1979 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE: Verification of Axial Power Imbalance failed to satisfy surveillance requirements Conditions Prior to Occurrence: The unit was in Mode 1, with Power (MWT) = 2440, and Load (Gross MWE) = 819.
Description of Occurrence:
On February 19,1979, at 0015 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br />, process computer display Group 38 (tilt, imbalance insertion) on the Control Room cathode ray tube (CRT) was observed to have stopped updating. Group 38 was declared inoperable on February 19, 1979 at 0015 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br />. With Group 38 display inoperable, the axial power imbalance alarm becomes inoperable, thus requiring an increase in the frequency of surveillance requirements per Technical Specification 4.2.1.
Technical Specifica-tion 4.2.1 requires the axial power imbalance to be determined to be within limits once every 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> when above 40% of rated thermal power except when the axial power imbalance alarm is inoperable, then calculate the axial power imbalance at least once per hour. The axial power imbalance manual calculation, Surveillance Test ST 5020.01, specifies Section 7.1 is to be performed hourly to satisfy sur-veillance requirements of Technical Specification 4.2.1 when Group 38 is inoperable.
Section 7.1 of ST 5020.01 verifies axial power imbalance by a calculation which utilizes computer points C927 and C928.
Section 7.1 of ST 5020.01 was performed hourly from 0015 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br /> until 0215 hours0.00249 days <br />0.0597 hours <br />3.554894e-4 weeks <br />8.18075e-5 months <br /> on February 19, 1979, when it was discovered that computer points C927 and C928 were not updating. With computer points C927 and C928 inoperable, Section 7.1 f ailed to satisfy surveillance requirements for Technical Specification 4.2.1.
Section 7.4 was then performed from 0220 hours0.00255 days <br />0.0611 hours <br />3.637566e-4 weeks <br />8.371e-5 months <br /> to 0720 hours0.00833 days <br />0.2 hours <br />0.00119 weeks <br />2.7396e-4 months <br />, satisfying surveillance require-ments for Technical Specification 4.2.1.
Section 7.1 of ST 5020.01 was inadvertently performed from 0820 hours0.00949 days <br />0.228 hours <br />0.00136 weeks <br />3.1201e-4 months <br /> until 1220 hours0.0141 days <br />0.339 hours <br />0.00202 weeks <br />4.6421e-4 months <br /> when it was discovered that computer points C927 and C928 were not updating.
Section 7.3 of ST 5020.01 was then performed at 1320 hours0.0153 days <br />0.367 hours <br />0.00218 weeks <br />5.0226e-4 months <br /> and continued to be per-formed hourly until Group 38 was declared operable on February 20,1979 at 0002 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />, satisfying surveillance requirements for Technical Specification 4.2.1.
Surveillance requirements for Technical Specification 4.2.1 were therefore not satisfied from 0115 hours0.00133 days <br />0.0319 hours <br />1.901455e-4 weeks <br />4.37575e-5 months <br /> to 0215 hours0.00249 days <br />0.0597 hours <br />3.554894e-4 weeks <br />8.18075e-5 months <br /> and from 0820 hours0.00949 days <br />0.228 hours <br />0.00136 weeks <br />3.1201e-4 months <br /> to 1220 hours0.0141 days <br />0.339 hours <br />0.00202 weeks <br />4.6421e-4 months <br /> on Febru-ary 19,1979 due to Section 7.1 of ST 5020.01 being performed with bad data result-ing from inoperable computer points.
Group 38 was declared operable on February 20, 1979 at 0002 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />.
r Designation of Apparent Cause of Occurrence:
The apparent cause of the occurrence was procedural deficiency. A random hardware f ailure in the Bailey Computer System caused Group 38 and canputer points C927 and C928 to stop updating.
ST 5020.01 calls for Section 7.1 to be used to satisfy surveillance requirements of Technical Specification 4.2.1 when Group 38 is inoperable. Unaware that the hardware f ailure LER #79-031
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TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE PAGE 2 SUPPLEMENTAL INFORMATION FOR LER NP-33-79-35 had also caused computer points C927 and C928 to be inoperable, Section 7.1 was performed until the discovery of the inoperable camputer points. The procedure (ST 5020.01) was deficient in that there was no warning or caution that when Group 38 fails to update, there is a possibility that computer points C927 and C928 will not be operable.
Analysis of Occurrence: There was no danger to the health and safety of the public or to unit personnel. A review of hourly axial power imbalance data taken from the computer daily log sheets, indi:ated that the axial power imbalance did not exceed Technical Specification limits during the occurrence.
Corrective Action
Upon the discovery of the inoperable computer points C927 and C928 at 0215 hours0.00249 days <br />0.0597 hours <br />3.554894e-4 weeks <br />8.18075e-5 months <br /> on February 19, 1979, Surveillance Test ST 5020.01, Section 7.4 was performed instead of Section 7.1 of ST 5020.01 in order to satisfy Technical Specification 4.2.1.
Upon the discovery of the inoperable computer points at 1320 hours0.0153 days <br />0.367 hours <br />0.00218 weeks <br />5.0226e-4 months <br /> on February 19, 1979, Section 7.3 of ST 5020.01 was performed ~and was con-tinued to be performed throughout the remainder of the inoperability of Group 38.
A modification to ST 5020.01, T-3538, has been written to caution operators that when Group 38 fails to update, there is a possibility that computer points C927 and C928 will also be inoperable.
Failure Data: There has been one prior occurrence of the failure to satisfy axial power imbalance surveil ance requirements, previously reported in Licensee Event Report NP-33-78-136.
LER #79-031
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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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