LER-1977-017, /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 |
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| 3461977017R01 - NRC Website |
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4 60 6i DOCKET NUM8ER 68 69 EVENT OATE 74 75 REPORT OATE 80 EVENT DESCRIPTION AND PROBABLE CONSEQUENCES O10 Io # 21 l At 1150 hours0.0133 days <br />0.319 hours <br />0.0019 weeks <br />4.37575e-4 months <br /> on October 20, 1977, iT was discovered that both Auxiliary Feed Pump l
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.i2 42 44 47 CAUSE DESCRIPTION AND CCRRECTIVE ACTIONS l i i o l l The cause of this occurrence is personnel error. At 0139 hours0.00161 days <br />0.0386 hours <br />2.29828e-4 weeks <br />5.28895e-5 months <br /> on October 20, 1977, ;
li1ij l an operator improperly lined up the Startup Feed Pump to run with suction from the I
The valve W 85 was locked l
t 21 1 Deaerator Storage Tanks through W 85 instead of W 32.
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DVR 145-1 Rich Chesko
.a TOLEDO EDISON COMPANY b' '
DAVIS-BESSE UNIT ONE NUCLEAR POWER STATION SUPPLEMENTAL INFORMATION FOR LER NP-32-77-17 DATE OF EVENT: October 20, 1977 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE: Improper cooling water supply to both Auxiliary-Feed Pumps due to pump suction being aligned to deaerators and cooling water not being shifted to Service Water.
Conditions Prior to Occurrence: The plant was in Mode 1, with Power (MWI) = 166, and Load (MWE) = 0.
Description of Occurrence: At 1150 hours0.0133 days <br />0.319 hours <br />0.0019 weeks <br />4.37575e-4 months <br /> on October 20, 1977, it was discovered that both Auxiliary Feed Pump (AFP) suctions were lined up to the Deserator Storage Tanks (DST) without the cooling water supply beiag shifted to Service Water. This lineup provided greater than 200 F water as cooling water for the Auxiliary Feed 0
Pump Turbine bearings. This rendered both Auxiliary Feed Pumps inoperable placing the station in violation of Technical Specification 3.7.1.2.
O At 1200 hours0.0139 days <br />0.333 hours <br />0.00198 weeks <br />4.566e-4 months <br /> on October 20, 1977, the lineup was shifted by closing W 85 to have both AFP's taking their suction from the Condensate Storage Tanks instead of the DST, thus restoring the cooling water. supply and removing the station from the Action Statement.
Designation of Apoarent Cause of Occurrence: The cause of this occurrence is per-sonnel error. At 0139 hours0.00161 days <br />0.0386 hours <br />2.29828e-4 weeks <br />5.28895e-5 months <br /> on October 20, 1977, an operator improperly lined up the Startup Feed Pump to run with suction from the DST's through W 85 instead of W 32.
This allowed the hot water to be lined up to the AFP's.
]
Analysis of Occurrence: There was no threat to the health and safety of the public or to station personnel. If the AFP's were called upon (which they were not), they would have automatically started and performed their safety function. Since the hot water from the Demerator Storage Tanks would not provide adequate cooling for continuous running of the Auxiliary Feed Pumps without some additional operator action, both AFP's were considered inoperable. However, the installed bearing temperature alarms would have alerted the Control Room Operator of the problem soon after starting the pumps as the hot water would have allowed the bearing oil temperature to reach the alarm setpoint. At this time shifting of the cooling water supply or the closing of W 85 would have eliminated the problem.
)
TOLEDO EDISON COMPANY DAVIS-BESSE UNIT ONE NUCLEAR POWER STATION SUPPLEMENTAL INFORMATION FOR LER NP-32-77-17 PAGE 2
Corrective Action
The valve W 85 was locked closed and a procedure modification was issued to the AFP Monthly Surveillance Test, ST 5071.01, to add W 85 as locked closed to the Valve Verification List.
Failure Data: There have been no previous occurrences caused by improper cooling water lineup to the Auxiliary Feed Pumps.
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| 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 | |
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