LER-1977-078, /03L-0:on 771011,during Functional Test,Reactor Protection Sys Channel 1 Accidentally de-energized.Caused by Error in Maint Work Order.Personnel Instructed |
| Event date: |
|
|---|
| Report date: |
|
|---|
| 3461977078R03 - NRC Website |
|
text
___
U.S. NUCLEAR REGULATORY COMMlWON m
NRC FORM 364 p.nl LICENSEE EVENT REPORT
'NTRCL 'SLOCK: l l
l l
l I lh (PLEASE PRINT OR TYPE ALL REQUIREO INFORMATION)
I 6
l 01 Hl D l 31 Sl 1l@l 610 l -l 01 OlNlPlFl-l 0l3l(l4l1l111l1l@l l
j@
~
8 9 UCENSEE CooE 14 15 uCENSE NUMBER 25 26 UCENSE TYPE J0 Si CAT 54 CON'T loill
$URC IL hl01310l-l61314I5 @lll0!Illl717 @lllllOl31717l@
7 8
60 61 COCK ET NUMSER 6a 69 EVENT DATE 74 75 REPORT DATE 60 EVENT DESCRIPTION AND PRCSABLE CONSEQUENCES h I o 121 l At 1450 hours0.0168 days <br />0.403 hours <br />0.0024 weeks <br />5.51725e-4 months <br /> on October 11, 1977 while performina ST 5C30.12, " Channel Functional I
l Test of the Reactor Trip Module Logic and Control Rod Drive Trip Breakers", Reactor i
g o l3; ITTT1 1 Protection System (RPS) Channel 1 was accidentally de-energized. This de-energized i
I the power supply for Source Range Detector NI-2 placing the station in the Action I
Ioisl l o is 1 I Statement of Technical Soecification 3.3.'..l.
The redundant Source Ranga Detector.
1 [ot'n l NI-l was operable and in service.
(NP-33-77-78)
_ _j I
i o Ia i 1
- S*E TcE SuiciSE COMPONENT CODE SusCOO'E S
E Co l Il El@ lD l@ lz l@ l Il NI Sl Tl Rl Ul@ l Xl@ W @
lol9I 7
8 9
to 11 i2 13 18 19 IQ SEoVENTIAL OCCURRENCE REPORT REVISloN LER EVENT YEAR REPORT No.
Co0E TYPE No.
@,aeg/Ro I 71 71 1-1 1 01 718 l y
l 6131 ltl
[__l l 0l p4 y
,,,,, 21 22 23 24
- 6 27 28 23 30 31 32 N
C o oP T
ME e4 HoVR3 S B I PoR B.
SUPPLI ER
l Z l@
lZ lh l7 0l 0l 0l 0l l Yl g l Nl g l Nl @
l3 l 0] 4l 0l@
33 34 35 Of 3
40 el 43 43 4A 47 CALSE DESCRIPTION AND CORRECTIVE ACTIONS I
y IThe cause of the occurrence was an error in the Maintenance Work Order which g i li l lprovided the instructions for the Surveillance Test. The work order called for i
l i 6 21 l jLmpe.s to be used on the pins of a linear bridge output which was tenoor trily
__]
lil3l l removed for maintenance, causing a trd.p of the power suoply.
l li ta l 1 I
40 7
8 9 STA
% POWER oTHER STATUS QLS o RY DISCOVERY DESCRIPT1oN lii$i LBJ@ 10 I ol 0!@l NA I
I Al@l NA I
i2 n
u 4
.0 8,g,,, 4,
7 RELEASED op RELEASE AMouNTop ACTIVITY LoCATL.4 op RELEASE Li Is l I Z I @ Iz l@l NA l
l NA l
7 8 9 to it 44 45 80 PERSCNNEL EXPOSURES NUM8ER TYPE
DESCRIPTION
NA l
11711010101@lzl@l
,;RSo~~E'L,N2u'R'iES ESCRiPTioN@
NuusER 1010101@l NA l
50 8 9 11 LOSS op oR DAMAGE To PACILITY LIJ@l NA o n o 1150 / N l
TYPE DESCRIPTICN 7
8.9 10-80 u.u i N f8lf CRiptioNh
~
,SSu s o
NA i
liiiiiiiiiiill 68 69 30 ;
7 8 3 to i hens 419-259-5000. Nr.
'"i1 2
'DVR 139-1 NAMt: OF PREPARER pyngg;
i i
}
,O)
~
DAVIS-BESSE UNIT ONE NUCLEAR POWER STATION
\\
TOLEDO EDIS0rt COMPANY SUPPLEF"'NTAL INFORMATION FOR LER NP-33-77-78 i
DATE OF EVENT: October 11, 1977 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE: Loss of Source Range Neutron Flux Detector NI-2 indication.
Conditions Prior to Occurrence: The plant was in !! ode 3, with Power (MWT) = 0, and Load (MWE) = 0.
Technical Specification 3.3.1.1 was applicable as the Cnntrol Rod Drive Trip Breakers were closed and the Control Rod Drive System was capable of rod withdrawal.
Decription of Occurrence: At 145C hours on October 11, 1977, while performing Surveillance Test, ST 3030.12, " Channel Functional Test of the Reactor Trip Module Logic and Control Rod DriveTrip Breakers", Reactor Protection System (RPS)
Channel 1 was accidentally de-energized. This de-energi=ed the po'sar supply for
/~rce Range Detector NI-2 placing the station in the Action Statement of Techni-l' Specific.ation 3.3.1.1.
The redundant Source Range Detector, NI-1, was opera-( ))and in service.
D:signation of Anoarent Cause of Occurrence: The cause of this occurrence was an Error in the Maintenance Work order (MWO) which provided the instructions for the Surveillance Test.
The linear bridge for RPS Channel 1, Reactor Coolant System (RCS) Temperature String had been returned to the vendor for rework. The RPS is such that whenever a module is missing the char tel trips.
With the linear bridge missing, the resistance input to the temperature signal converter is infinite causing the high temperature trip bistable to trip. The MWO instructed the Instrument and Control (ISC) Mechanic to jumper the pins which correaponded to the missing =odule interlock and the high temperature trip bistablas trip contacts. When the jumpers were placed, the power supply was thtrted to ground. This caused the system power supplies to trip on overcurrent, de-energizing the channel.
ThIse instructions on the MWO were in error.
It should have instructed the I&C M chanic to place the channel in Channel Bypass. This would have allowed the ptrformance of the Surveillance Test wf thout the installation of jumpers.
Analysis of Occurrence: There was no danger to the health and safety of the public cr to station personnel.
This thermal power level was maintained at less than 0-10 amps on the Intermediate Range Flux Instrumentation.
l I
t i
h
l w*
4 TOLEDO EDISON COMPANY DAVIS-BESSE UNIT ONE NUCLEAR POWER STATION SUPPLLMENTAL INFORMAIION FOR LER NP-33-77-78 PAGE 2
Corrective Action
The I&C Mechanic was instructed to remove the jumpers and Operations personad then re-energized the channel, in accordance with SP 1105.02, " Reactor Protection System and Nuclear Instrumentation Operating Procedure". At approximately 1530 hours0.0177 days <br />0.425 hours <br />0.00253 weeks <br />5.82165e-4 months <br /> on October 11, 1977, Source Range Detector NI-2 was re-energized which removed the station from the Action State-ment of Technical Specification 3.3.1.1.
Failure Data: No previous losses of Source Range Nuclear Instrumentat. ion were caused by maintenance instruction errors.
O 1
9% Og S, %
.c _. -
i N
4 5-
--p-y
,>m-,gs-
- - wy,,.
y- - --,-
y-wm-v----ye-m
|
|---|
|
|
| | | Reporting criterion |
|---|
| 05000289/LER-1977-016-01, /01T-0:on 770924,RCS Temp & Pressure Rose.Caused by Half Trip Condition from Steam & Feedwater Rupture Control Sys.Possible Cause of Half Trip Attributed to Loose Connection at Terminal Boards | /01T-0:on 770924,RCS Temp & Pressure Rose.Caused by Half Trip Condition from Steam & Feedwater Rupture Control Sys.Possible Cause of Half Trip Attributed to Loose Connection at Terminal Boards | | | 05000289/LER-1977-016, Forwards Supplemental Info to LER 77-016/01T-0 Re Half Trip in Steam Feedwater Rupture Control Sys | Forwards Supplemental Info to LER 77-016/01T-0 Re Half Trip in Steam Feedwater Rupture Control Sys | | | 05000320/LER-1977-016, /01T-0 on 770924:half Trip of Steam & Feedwater Rupture Control Sys Resulted in Opening of Pressurizer Power Relief Valve.Possibly Caused by Loose Connections at Terminal Boards | /01T-0 on 770924:half Trip of Steam & Feedwater Rupture Control Sys Resulted in Opening of Pressurizer Power Relief Valve.Possibly Caused by Loose Connections at Terminal Boards | | | 05000346/LER-1977-017, Forwards LER 77-017/01T-0 | Forwards LER 77-017/01T-0 | | | 05000346/LER-1977-017-01, /01T-0:on 771020,both Auxiliary Feed Pump Suctions Lined Up to Deaerator Storage Tanks W/O Cooling Water Supply Shifting to Svc Water,Resulting in Water Greater than 200 F as Cooling Water for Auxiliary Feed Pump Bearings | /01T-0:on 771020,both Auxiliary Feed Pump Suctions Lined Up to Deaerator Storage Tanks W/O Cooling Water Supply Shifting to Svc Water,Resulting in Water Greater than 200 F as Cooling Water for Auxiliary Feed Pump Bearings | | | 05000346/LER-1977-018, Forwards LER 77-018/01T-0 | Forwards LER 77-018/01T-0 | | | 05000346/LER-1977-018-01, /01T-0:on 771108,station Review Board Found Auxiliary Feed Pump Turbine Governor Valve Vibrational Closure Design Deficiency.Caused by Lack of Force to Hold Valve Open.Requests Design Mod for Pump Turbines | /01T-0:on 771108,station Review Board Found Auxiliary Feed Pump Turbine Governor Valve Vibrational Closure Design Deficiency.Caused by Lack of Force to Hold Valve Open.Requests Design Mod for Pump Turbines | | | 05000346/LER-1977-019-01, /01T-0:on 771117,auxiliary Feedwater Valves AF 599 & AF 608 Found Closed,Rendering Steam & Feedwater Rupture Control Sys Pressure Switch Inputs Inoperable.Caused by Procedural Deficiency.Tests Revised | /01T-0:on 771117,auxiliary Feedwater Valves AF 599 & AF 608 Found Closed,Rendering Steam & Feedwater Rupture Control Sys Pressure Switch Inputs Inoperable.Caused by Procedural Deficiency.Tests Revised | | | 05000346/LER-1977-019, Forwards LER 77-019/01T-0 | Forwards LER 77-019/01T-0 | | | 05000346/LER-1977-077-03, /03L-0:on 771010,decay Heat Valve Pit Cover Removed to Inspect Decay Heat Isolation Valves DH11 & DH12 & to Perform Wiring Change on DH12.Insp Required for Leakage & Preventive Maint | /03L-0:on 771010,decay Heat Valve Pit Cover Removed to Inspect Decay Heat Isolation Valves DH11 & DH12 & to Perform Wiring Change on DH12.Insp Required for Leakage & Preventive Maint | | | 05000346/LER-1977-077, Forwards LER 77-077/03L-0 | Forwards LER 77-077/03L-0 | | | 05000346/LER-1977-078-03, /03L-0:on 771011,during Functional Test,Reactor Protection Sys Channel 1 Accidentally de-energized.Caused by Error in Maint Work Order.Personnel Instructed | /03L-0:on 771011,during Functional Test,Reactor Protection Sys Channel 1 Accidentally de-energized.Caused by Error in Maint Work Order.Personnel Instructed | | | 05000346/LER-1977-078, Forwards LER 77-078/03L-0 | Forwards LER 77-078/03L-0 | | | 05000346/LER-1977-079-03, /03L-0:on 771011,source Range Defector NI-1 Indication Failed Low Twice,Then Returned to Normal Operation by Itself.Cause Unknown | /03L-0:on 771011,source Range Defector NI-1 Indication Failed Low Twice,Then Returned to Normal Operation by Itself.Cause Unknown | | | 05000346/LER-1977-079, Forwards LER 77-079/03L-0 | Forwards LER 77-079/03L-0 | | | 05000346/LER-1977-080, Forwards LER 77-080/03L-0 | Forwards LER 77-080/03L-0 | | | 05000346/LER-1977-080-03, /03L-0:on 771016,governor Valve on Auxiliary Feed Pump 1-2 Found Closed During Auxiliary Feedwater Sys Monthly Test Performance.Caused by Possible Design Deficiency. Excessive Vibration Under Investigation by Maint Personnel | /03L-0:on 771016,governor Valve on Auxiliary Feed Pump 1-2 Found Closed During Auxiliary Feedwater Sys Monthly Test Performance.Caused by Possible Design Deficiency. Excessive Vibration Under Investigation by Maint Personnel | | | 05000346/LER-1977-081, Forwards LER 77-081/03L-0 | Forwards LER 77-081/03L-0 | | | 05000346/LER-1977-081-03, /03L-0:on 771018,during Miscellaneous Instrument Shift Checks,Containment to Annulus Differential Pressure Exceeded Water Gauge Tech Spec Limit.Caused by Procedure & Personnel Error.Startup Procedure Modified | /03L-0:on 771018,during Miscellaneous Instrument Shift Checks,Containment to Annulus Differential Pressure Exceeded Water Gauge Tech Spec Limit.Caused by Procedure & Personnel Error.Startup Procedure Modified | | | 05000346/LER-1977-082-03, /03L-0:on 771019,discharge & Recirculation Dampers of Emergency Ventilation Sys 2 Failed to Open When Fan Started.Caused by Loose & Dirty Controller Contacts.Module Removed & Reinserted, & Contacts Cleaned | /03L-0:on 771019,discharge & Recirculation Dampers of Emergency Ventilation Sys 2 Failed to Open When Fan Started.Caused by Loose & Dirty Controller Contacts.Module Removed & Reinserted, & Contacts Cleaned | | | 05000346/LER-1977-082, Forwards LER 77-082/03L-0 | Forwards LER 77-082/03L-0 | | | 05000346/LER-1977-083, Forwards LER 77-083/03L-0 | Forwards LER 77-083/03L-0 | | | 05000346/LER-1977-083-03, /03L-0:on 771025,stop Valve AF3872 Failed to Stroke When Given Open Signal.Caused by Component Failure. Torque Switch Replaced on 771027 | /03L-0:on 771025,stop Valve AF3872 Failed to Stroke When Given Open Signal.Caused by Component Failure. Torque Switch Replaced on 771027 | | | 05000346/LER-1977-084, Forwards LER 77-084/03L-0 | Forwards LER 77-084/03L-0 | | | 05000346/LER-1977-084-03, /03L-0:on 771025,surveillance Test ST 5080.01 Not Performed.Caused by Personnel Error.Test Performed Immediately & Computer Program Revised | /03L-0:on 771025,surveillance Test ST 5080.01 Not Performed.Caused by Personnel Error.Test Performed Immediately & Computer Program Revised | | | 05000346/LER-1977-086-03, /03L-0:on 771028,safety Features Actuation Sys Channel 4 Radiation Monitor RIS 2007 Failed to Respond to Internal Check Source.Caused by Component Failure.Low Amplifier Board Replaced & Monitor Recalibr | /03L-0:on 771028,safety Features Actuation Sys Channel 4 Radiation Monitor RIS 2007 Failed to Respond to Internal Check Source.Caused by Component Failure.Low Amplifier Board Replaced & Monitor Recalibr | | | 05000346/LER-1977-086, Forwards LER 77-086/03L-0 | Forwards LER 77-086/03L-0 | | | 05000346/LER-1977-087, Forwards LER 77-087/03L-0 | Forwards LER 77-087/03L-0 | | | 05000346/LER-1977-087-03, /03L-0:on 771024,safety Features Actuation Sys Channel 3 Containment Radiation Reaqdings Unreliable . Caused by Design/Fabrication Error.Facility Change Request 77-437 Issued for Permanent Repair | /03L-0:on 771024,safety Features Actuation Sys Channel 3 Containment Radiation Reaqdings Unreliable . Caused by Design/Fabrication Error.Facility Change Request 77-437 Issued for Permanent Repair | | | 05000346/LER-1977-088, Forwards LER 77-088/03L-0 | Forwards LER 77-088/03L-0 | | | 05000346/LER-1977-088-03, /03L-0:on 771027,source Range Detector NI-1 Indication Failed Low.Cause Unknown.Updated Rept Forthcoming | /03L-0:on 771027,source Range Detector NI-1 Indication Failed Low.Cause Unknown.Updated Rept Forthcoming | | | 05000346/LER-1977-089-03, /03L-1:on 771107,radiation Monitor RIS 2007 Was Showing Erratic Readings.Caused by Victoreen Low Range Amplifier Board 847-1-20 Failure.Board Replaced | /03L-1:on 771107,radiation Monitor RIS 2007 Was Showing Erratic Readings.Caused by Victoreen Low Range Amplifier Board 847-1-20 Failure.Board Replaced | | | 05000346/LER-1977-089, Forwards LER 77-089/03L-1.W/o Encl | Forwards LER 77-089/03L-1.W/o Encl | | | 05000346/LER-1977-090-03, /03L-0:on 771107,during Review of Deficiency in Steam & Feedwater Rupture Control Sys Monthly Test,Reactor Coolant Pump Found Inoperable.Caused by Component Failure. Voltage Regulating Diode Replaced | /03L-0:on 771107,during Review of Deficiency in Steam & Feedwater Rupture Control Sys Monthly Test,Reactor Coolant Pump Found Inoperable.Caused by Component Failure. Voltage Regulating Diode Replaced | | | 05000346/LER-1977-090, Forwards LER 77-090/03L-0 | Forwards LER 77-090/03L-0 | | | 05000346/LER-1977-091-03, /03L-0:on 771107,containment Radiation Monitor RIS 2006 Spiked & Reset Twice Causing Safety Features Actuation Sys Incident Level 1 Trips.Caused by Design Error | /03L-0:on 771107,containment Radiation Monitor RIS 2006 Spiked & Reset Twice Causing Safety Features Actuation Sys Incident Level 1 Trips.Caused by Design Error | | | 05000346/LER-1977-091, Forwards LER 77-091/03L-0 | Forwards LER 77-091/03L-0 | | | 05000346/LER-1977-092, Forwards LER 77-092/03L-0 | Forwards LER 77-092/03L-0 | | | 05000346/LER-1977-092-03, /03L-0:on 771101,facility Review Board Meeting Revealed That Surveillance Requirement of Venting Hpis Valve HP 72 Not Performed.Caused by Personnel Error.High Point Valve Vented & Modified | /03L-0:on 771101,facility Review Board Meeting Revealed That Surveillance Requirement of Venting Hpis Valve HP 72 Not Performed.Caused by Personnel Error.High Point Valve Vented & Modified | | | 05000346/LER-1977-093, Forwards LER 77-093/03L-0 | Forwards LER 77-093/03L-0 | | | 05000346/LER-1977-093-03, /03L-0:on 771114,reactor Protection Sys Daily Heat Balance Check Not Completed When Station Above 15% Rated Thermal Power During Oct-Nov 1977.Caused by Personnel Error. Surveillance Test Placed on Daily Testing Schedule | /03L-0:on 771114,reactor Protection Sys Daily Heat Balance Check Not Completed When Station Above 15% Rated Thermal Power During Oct-Nov 1977.Caused by Personnel Error. Surveillance Test Placed on Daily Testing Schedule | | | 05000346/LER-1977-094-03, /03L-0:on 771116,emergency Ventilation Sys Dampers Pdv 5014A & B Failed to Modulate Correctly to Draw Down Annulus.Caused by Defective Pressure Differential Controller.Dampers Replaced & Sys Retested | /03L-0:on 771116,emergency Ventilation Sys Dampers Pdv 5014A & B Failed to Modulate Correctly to Draw Down Annulus.Caused by Defective Pressure Differential Controller.Dampers Replaced & Sys Retested | | | 05000346/LER-1977-094, Forwards LER 77-094/03L-0 | Forwards LER 77-094/03L-0 | | | 05000346/LER-1977-095-03, /03L-0:on 771127,control Room Ventilation Isolation Damper HV 5311A Failed to Close on Radiation Monitor Trip.Caused by Component Failure.Damper Dismantled & Sealing Surfaces Cleaned & Lubricated | /03L-0:on 771127,control Room Ventilation Isolation Damper HV 5311A Failed to Close on Radiation Monitor Trip.Caused by Component Failure.Damper Dismantled & Sealing Surfaces Cleaned & Lubricated | | | 05000346/LER-1977-095, Forwards LER 77-095/03L-0 | Forwards LER 77-095/03L-0 | | | 05000346/LER-1977-097, Forwards LER 77-097/03L-0 | Forwards LER 77-097/03L-0 | | | 05000346/LER-1977-097-03, /03L-0:on 771129,radiation Monitor Re 2006 Tripped Safety Features Actuation Sys Channel 3 Containment Radiation Due to Sporadic Spiking.Caused by Component Failure in Radiation Detector.Detector Replaced | /03L-0:on 771129,radiation Monitor Re 2006 Tripped Safety Features Actuation Sys Channel 3 Containment Radiation Due to Sporadic Spiking.Caused by Component Failure in Radiation Detector.Detector Replaced | | | 05000346/LER-1977-100-03, /03L-0:on 771201 & 05,source Range Neutron Detector NI-1 Indication Dropped to Zero & Returned to Normal Operation W/O Assistance.Cause Unknown.After First Failure,Detector Replaced & Retested | /03L-0:on 771201 & 05,source Range Neutron Detector NI-1 Indication Dropped to Zero & Returned to Normal Operation W/O Assistance.Cause Unknown.After First Failure,Detector Replaced & Retested | | | 05000346/LER-1977-100, Forwards LER 77-100/03L-0 | Forwards LER 77-100/03L-0 | | | 05000346/LER-1977-101-03, /03L-0:on 771201,diesel Generator 1-1 Inoperable Due to Failure to Perform Required Surveillance Testing on Diesel Generator 1-2 within Required Tech Spec Interval. Caused by Personnel Error | /03L-0:on 771201,diesel Generator 1-1 Inoperable Due to Failure to Perform Required Surveillance Testing on Diesel Generator 1-2 within Required Tech Spec Interval. Caused by Personnel Error | |
|