LER-1979-023, /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 |
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U.S. NUCLEAR REGULATORY CoMMIS510N NRC FORM 366 (7 77)
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8 60 61 DOCKET NUV8ER 63 69 EVENT DATE 74 75 REPORT DATE 80 EVENT DESCRIPTION AND PROBABLE CONSEQUENCES h l o 12 l l At 0532 hours0.00616 days <br />0.148 hours <br />8.796296e-4 weeks <br />2.02426e-4 months <br /> on 2/28/79, Startup Transfomer 01 was taken out of service for adjust-1 I o I a l l ments. This immediately entered the unit into Action Statement (a) of Tech Spec l
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NAME OF PREPARER.
TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-32-79-01 DATE.0F EVENT:
February 28, 1979 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE:
Failure to comply to Technical Specifications with Startup Transformer 01 out of service Conditions Prior to Occurrence: The unit was in Mode 1, with Power (MUT) = 2341, and Load (Gross MWE) = 792.
Description of Occurrence: At 0532 hours0.00616 days <br />0.148 hours <br />8.796296e-4 weeks <br />2.02426e-4 months <br /> on February 28, 1979, 345 KV - 13.8 KV Startup Transf ormer "01" was taken out of service for transformer tap setting adjust-ments. This Lamediately entered the unit into Action Statement (a) of Technical Speci-fication 3.8.1.1.
Action Statement (a) o f Technical Specification 3.8.1.1 requires operations personnel to verify correct breaker alignment and power availability by performing Surveillance Test ST 5080.01, " Independent Off-Site AC Sources Lined up and Available", and to verify that each Emergency Diesel Cencrator is operable by perform-ing Surveillance Test ST 5081.01, " Diesel Generator Monthly Test", within one hour and every eight hours thereafter until the transformer is placed back in service. Opera-tions personnel misinterpreted this Action Statement and failed to do the required surveillance testing.
At 0730 hours0.00845 days <br />0.203 hours <br />0.00121 weeks <br />2.77765e-4 months <br /> on February 28, 1979, operations personnel realized that Surveillance Tests ST 5080.01 and ST 5081.01 should have been performed, and testing was completed by 0744 hours0.00861 days <br />0.207 hours <br />0.00123 weeks <br />2.83092e-4 months <br /> on February 28, 1979.
With the exception of the initial surveillance requirement, all other surveillance re-quirements were met until Startup Transformer "01" was returned to service at 1845 hours0.0214 days <br />0.513 hours <br />0.00305 weeks <br />7.020225e-4 months <br /> on February 28, 1979.
Taking Startup Transformer "01" out of service placed the unit in Action Statement (a) of Technical Specification 3.8.1.1 which states that two independent circuits between the offsite transmission network and the onsite distribution system each consisting of one operabic 345 KV transmission line, one operable 345 KV - 13.8 KV Startup Trans-former, one operable 13.8 KV Bus, and one operable Emergency Diesel Generator system be operable.
Failure to complete Surveillanco Tests ST 5080.01 and ST 5081.01 within one hour of taking Startup Transformer "01" out of service placed the unit in violation of Limit-ing Condition for Operation 3.0.3 which requires that in the event that a limiting condition f or operation and/or associated action requirements cannot be satisfied because of circumstances in excess of those addressed in the specifications, the unit shall be in hot standby within one hour and in cold shutdown within 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br /> unless corrective measures are completed.
LER #79-023
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TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE PAGE 2 OF 2 SUPPLDIENTAL INFORMATION FOR LER NP-32-79-01 Designation of Apparent Cause of Occurrence: This incident was caused by personnel Operations personnel misinterpreted Action Statement (a) of Technical Speci-error.
fication 3.8.1.1 and f ailed to perf orm the required surveillance.
Analysis of Occurrence: There was no danger to the health and safety of the public or to unit personnel. The alternate offsi.te AC electrical power source was in service supplying the auxiliary loads for the unit at the time of the incident and subsequent surveillance tests showed both Emergency Diesel Generators to be operable.
Corrective Action
At 0730 hours0.00845 days <br />0.203 hours <br />0.00121 weeks <br />2.77765e-4 months <br /> on February 28, 1979, operations personnel realized that ST 5080.01 and ST 5081.01 should have been performed. Testing was completed by 0744 hours0.00861 days <br />0.207 hours <br />0.00123 weeks <br />2.83092e-4 months <br /> on February 28, 1979.
Further corrective action will follow pending further investigation into the incident.
Failure Data:
There have been no previously reported similar incidents.
LER #79-023 e
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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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