05000346/LER-1980-060-01, /01T-0:on 800813,during Resetting of Trip Point, Decay Heat Isolation Valve Dh 11 Began Closing.Caused by Personnel Error.Dh 11 Reopened,Dh Pump 1-2 Started & Flow re-established.Tech Specs Amended

/01T-0:on 800813,during Resetting of Trip Point, Decay Heat Isolation Valve Dh 11 Began Closing.Caused by Personnel Error.Dh 11 Reopened,Dh Pump 1-2 Started & Flow re-established.Tech Specs Amended

ML19331D345
Person / Time
Site:	Davis Besse
Issue date:	08/26/1980
From:	Isley T TOLEDO EDISON CO.
To:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML19331D343	List: 05000346/LER-1980-060, Forwards LER 80-060/01T-0 05000346/LER-1980-060-01, /01T-0:on 800813,during Resetting of Trip Point, Decay Heat Isolation Valve Dh 11 Began Closing.Caused by Personnel Error.Dh 11 Reopened,Dh Pump 1-2 Started & Flow re-established.Tech Specs Amended
References
LER-80-060-01T, LER-80-60-1T, NUDOCS 8009020061
Download: ML19331D345 (3)

LER-1980-060, /01T-0:on 800813,during Resetting of Trip Point, Decay Heat Isolation Valve Dh 11 Began Closing.Caused by Personnel Error.Dh 11 Reopened,Dh Pump 1-2 Started & Flow re-established.Tech Specs Amended

Event date:
Report date:
3461980060R01 - NRC Website

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60 61 COCK ET NUP.*BE R 6d 63 EVENT DATE 74 75 REPORT DATE 80 EVENT DESCRIPTION AND PROBABLE CONSEQUENCES h ITTT1 1 (NP-32-80-14) On August 13, 1980 at 1320 hours0.0153 days <br />0.367 hours <br />0.00218 weeks <br />5.0226e-4 months <br />, I&C personnel, while working i

l in Safety Features Actuation System (SFAS) Channel 4 cabinet, were resetting the l

o 3 l trip point for bistable BA 413 for FCR 77-391 when Decay Heat (DH) Isolation Valve l

o 4 ITTT1 l DH 11 began closing. DH Pump 1-2 was stopped, placing the unit in violation of Tech-l os i nical Specification 3.4.1.

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33 34 36 36 31 40 di 42 43 44 47 CAUSE DESCRIPTION AND CORRECTIVE ACTIONS h g l The cause was personnel error in that the mechanic thought he had defeated the auto-l lmatic closing of DH 11 per the instructions in ST 5031.01. At 1321 hours0.0153 days <br />0.367 hours <br />0.00218 weeks <br />5.026405e-4 months <br />, DH 11 was l

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800902006/

TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION. UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-32-80-14 DATE OF EVENT: August 13, 1980 FACILITY: Davis-Besse Unit 1 j

IDENTIFICATION OF OCCURRENCE: Inadvertent loss of decay heat flow Conditions Prior to occurrence: The unit was in Mode.5, with Power (MWT) = 0 and Lord (Gross MWE) = 0.

Description of Occurrence: On August 13, 1980 at 1320 hours0.0153 days <br />0.367 hours <br />0.00218 weeks <br />5.0226e-4 months <br />, Instrument and Controls personnel were in Safety Features Actuation System (SFAS) Channel 4 Cabinet perform-ing work under Facility Change Request (FCR)77-391. Their actions caused Decay Heat Isolation Valve DH 11 to begin closing.

Decay Heat Pump 1-2 was i= mediately stopped to prevent possible damage due to loss of suction.

At 1321 hours0.0153 days <br />0.367 hours <br />0.00218 weeks <br />5.026405e-4 months <br />, DH 11 was reopened.

At 1323 hours0.0153 days <br />0.368 hours <br />0.00219 weeks <br />5.034015e-4 months <br />, Decay Heat Pu=p 1-2 was vented, and at 1325 hours0.0153 days <br />0.368 hours <br />0.00219 weeks <br />5.041625e-4 months <br /> the pu=p was started end flow re-established to the Reactor Coolant System.

This occurrence placed the unit in violation of Technical Specification 3.4.1 which requires a decay heat pump to be in operation while the unit is in Mode 5.

This incident is being reported in accordance with Technical Specification 6.9.1.8.b.

At 1407 hours0.0163 days <br />0.391 hours <br />0.00233 weeks <br />5.353635e-4 months <br />, the NRC was notified via the " red phone".

Luis Reyes (NRC Resident In-apsetor) was notified at 1430 hours0.0166 days <br />0.397 hours <br />0.00236 weeks <br />5.44115e-4 months <br /> on August 13, 1980.

Designation of Apparent Cause of Occurrence: The cause of the occurrence was person-nel error.

Instrument and Controls personnel were resetting the trip point for bi-stable BA 413 for FCR 77-391. The mechanic thought he had defeated the automatic closing of DH 11 per the instructions in ST 5031.01, SFAS Monthly Test. As he opened the slide link, he experienced some difficulty in getting it fully opened. Without having a positive position verification, the bistable was placed in test. The inter-lock actuated and DH 11 closed.

Analysis of occurrence: There was no danger to the health and safety of the public or to station personnel.

Decay heat flow was restored in five minutes and no increase in core temperature was noted.

During monthly testing of ST 5031.01 when the station is at power, the interlock does not cause a problem since the valve it closes is already closed.

Corrective Action

At 1321 hours0.0153 days <br />0.367 hours <br />0.00218 weeks <br />5.026405e-4 months <br /> on August 13, 1980, DH 11 was reopened and by 1325 Decay Heat Pump 1-2 was started and flow verified to the Reactor Coolant System.

The station was now in compliance with Technical Specification 3.4.1.

A check of the slide link and its physical location in the cabinet shows that although possible, it is diffi-cult to verify positive positioning of the link. Therefore, during the re=ainder of this facility change request work, the slide link will not be used to defeat the inter-lock.

Instead, station personnel are now aware of special permission to de-energize DH 11 and will do so to complete the resetting of the trip point for bistable BA 413.

LER #80-060

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o TOLEDO EDISON COMPMiY D*VIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-32-80-14 PAGE 2 Wh:n all of the work for FCR 77-391 is complete this outage, the station will be able to operate under Technical Specification Amendment 28 which eliminates the require-mint of always maintaining power on DH 11 and DH 12.

Frilure Data:

Previous loss of decay heat flow due to personnel error was reported in Licensee Event Reports NP-32-77-05, NP-32-77-09, !{P-33-80-54 (80-044) and NP-32-80-12 (80-058).

LER #80-060 I