LER-1980-058, /01T-0:on 800724,loss of Decay Heat Flow Observed Due to DH12 Going shut.DH11 Also Closed While Personnel Attempted to Restore Sfas CH4 Cabinet to Normal.Caused by Shorted Fuse Clip & Procedural Deficiency,Respectively |
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U.S. NUCLE AR REGULATORY COMt.ifSSION NRC FORM 3GG wm LICENSEE EVENT REPORT O
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60 61 DOCK ET NUVSER 68 63 EVENT DATE 74 75 REPORT DATE 80 EVENT DESCRIPTION AND PROBABLE CONSEQUENCES h roTT1 l(NP-32-80-12) On July 24, 1980 at 0955 hours0.0111 days <br />0.265 hours <br />0.00158 weeks <br />3.633775e-4 months <br />, the control room operators observed a losp 6
(bTil lof decay heat flow caused by DH12 going shut. Decay Heat Pump 1-2 was stopped. Bypass; I o I 4 l l valves DH21 and DH23 were opened and the pump restarted. At 2232 hours0.0258 days <br />0.62 hours <br />0.00369 weeks <br />8.49276e-4 months <br /> personnel were l l attempting to restore SFAS CH4 cabinet to normal when DH11 closed. Decay Heat Pump 1-2l IoIsl l o is ] lvas stopped until DH11 was reopened. On August 3,1980, I&C personnel removed bistable l The bistable was reinstalled and flow l
l o l 71 IBA413 and caused DH11 to close stopping flow.
1olal Ircstored.
Each event placed the unit in violation of Technical Specification 3.4.1.
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3J 34 35 36 31 40 41 42 43 44 41 CAUSE DESCRIPT.ON AND CORRECTIVE ACTIONS h itl0llThe first was caused by constructio3 electricians who were pulling wires into a cabinet!
li li j land shorted a fuse clip in the control circuit for Dill 2.
The second was caused by T> r o-l lcedural deficiency in that the MWO being used did not contain adequate restoration in-1 i 7 lstructions. The third event was caused by an arror by the maintenance specialist. Thel i 3 I
levents have been reviewed with the involved personnel.
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DESCRIPTION
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TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR PCWER STATION UNIT ONE.
SUPPLEMENTAL INFORMATION FOR LER NP-32-80--12 DATE OF EVENT: July 24, 1980 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE: Loss of Decay Heat Flow Conditions Prior to Occurrencei The unit was in Mode 5, with Power (MWT) = 0 and Load (Gross MWE) = 0.
Description of Occurrence:
At 0955 hours0.0111 days <br />0.265 hours <br />0.00158 weeks <br />3.633775e-4 months <br /> on July 24, 1980, the control room operators observed a loss of decay heat flow. They noticed that there was no indication for the valve position of Decay Heat Isolation Valve DH12. The running Decay Heat Pump 1-2 was stopped to prevent damage due to a loss of suction. At 1011 hours0.0117 days <br />0.281 hours <br />0.00167 weeks <br />3.846855e-4 months <br /> the bypass valves (DH21 and DH23) were opened and system venting began. At 1045 hours0.0121 days <br />0.29 hours <br />0.00173 weeks <br />3.976225e-4 months <br /> the DH Pump 1-2 was restarted and 1300 gpm flow verified. Decay heat flow was lost for a 50 minute period.
At 2232 hours0.0258 days <br />0.62 hours <br />0.00369 weeks <br />8.49276e-4 months <br /> on July 24, 1980, personnel were attempting to clear lights on SEAS Channel 4 following Instrument and Controls personnel completion of Facility Change Request (FCR) 79-439A. Unaware that the trip circuit for Decay Heat Isolation Valve DH11 had been restored, he adjusted the constant current adjustment potentiometer (CCAP) switch level. This caused the output bistable (B/S) BA413 to reset, which resulted in the DH Isolation Valve DH11 to close. DH Pump 1-2 was tripped immediately by the operator. At 2234 DH11 was reopened and the pump restarted with flow of 1300 gpm verified. Decay heat flow was lost for a 2 minute period.
At 1554 hours0.018 days <br />0.432 hours <br />0.00257 weeks <br />5.91297e-4 months <br /> on August 8,1980, Instruments and Controls personnel were performing work on bistabic BA413 under MWO IC 547-80. When the bistable was removed, isolation valve Dull went closed. Decay Heat Pump 1-1 was stopped to prevent damage. This caused decay heat flow to be stopped for 3 minutes until the bistable could be replaced and the pump restarted.
These occurrences placed the unit in violation of Technical Specification 3.4.1 which requires at les. one decay heat pump be in operation while the unit is in Mode 5.
l Designation of Apparent Cause of Occurrence:
The cause of the 0955 hour0.0111 days <br />0.265 hours <br />0.00158 weeks <br />3.633775e-4 months <br /> occurrence was personnel error. While working in disconnect cabinet CDE-1182, construction electricians were pulling wires and shorted out a fuse clip. This blew the 3 amp fuse in the valve control circuit causing DH12 to travel closed.
LER 80-058 i
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,n TOLETA.). EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE PAGE 2 SUPPLEMENTAL INFORMATION FOR LER NP-32-80-12 The occurrence at 2232 hours0.0258 days <br />0.62 hours <br />0.00369 weeks <br />8.49276e-4 months <br /> was attributed to procedural inadequacy.
In-sufficient guidance on the Maintenance Work Order (MWO) covering the work, with regards to system restoration, led to steps being done out of sequence.
The personnel were under the impression that TP35 slide link was open and TB35 points 25 and 26 were jumpered per ST5031.01, SFAS Monthly Test, which was being performed to check out Maintenance Work Order IC FCR79-439A SF^S
- - Reactor Coolant System Pressure to T-Sat.
In fact an I&C Technician had just removed the TP35 slide link and the jumper for TB35 points 25 and 26, to establish the normal system condition.
The occurrence at 1554 hours0.018 days <br />0.432 hours <br />0.00257 weeks <br />5.91297e-4 months <br /> on August 3, 1980, was attributed to personnel The maintenance specialist had previously reviewed the SFAS drawings error.
for the MWO and concluded the bistable could be removed with no special pre-cautions. He incorrectly determined that the bistable de-energized the output relay to allow DH11 to open, when actually the relay is energized by bistable BA413 to allow DH11 to open.
Analysis of Occurrence:
There was no danger to the health and safety of the public or to station personnel.
In all three cases the loss of decay heat flow caused no significant increase in RCS temperature. There was no damage to the DH pump since it was stopped immediately when the valve was confirmed shut.
Corrective Action
The first event was corrected by opening the DH11 and 12 bypass valves DH21 and DH23. DH pump 1-2 was revented and restarted on the bypass at 1045 hours0.0121 days <br />0.29 hours <br />0.00173 weeks <br />3.976225e-4 months <br />.
The blown fuse was replaced, DH11 and DH12 were opened at 1051 hours0.0122 days <br />0.292 hours <br />0.00174 weeks <br />3.999055e-4 months <br />, and DH21 and DH23 were closed.
Flow was verified at 1300 gpm.
The details of the event and electrical work practices was discussed with the construction'electri~cian
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and his supervisor.
In the second case where DH flow was lost, DH11 was re-opened. DH pump 1-2 was
. restarted and flow verified at.1300 gpm. Additional, pertinent guidance will be provided on future Maintenance Work Order's with regards to system restoration.
In the third event the bistable was re-installed. DH11 was opened and pump 1-1 was started.
Flow was restored by 1457 hours0.0169 days <br />0.405 hours <br />0.00241 weeks <br />5.543885e-4 months <br /> on August 3, 1980. A tag will be attached to this module indicating thateits removal will allow DH11 to go closed.
Two modules controlling Core Flood valves have be'en identified as operating in a similar manner, and will also be tagged to prevent inadvertent closing of the valves.
The maintenance specialist who made the error was cautioned to use more diligence in doing his work.
Failure Data:
Previous loss of decay heat flow due to personnel errors were reported in NP-32-77-05, j,
32-77-09, and 33-80-54.
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Previous losses of decay heat flow due to procedural error were reported in NP-32-77-3 and NP-33-80-53(80-043).
i LER 80-058 t
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| 05000346/LER-1980-001, Forwards LER 80-001/01T-0 | Forwards LER 80-001/01T-0 | | | 05000346/LER-1980-001-01, /01T-0:on 800103,during Plant Heatup,Safety Features Actuation Sys Channels 1 & 3 Tripped at 1,600 Psig, Causing Level 2 Actuation.Operators Correctly Tripped Reactor Coolant Pumps.Caused by Procedural Deficiency | /01T-0:on 800103,during Plant Heatup,Safety Features Actuation Sys Channels 1 & 3 Tripped at 1,600 Psig, Causing Level 2 Actuation.Operators Correctly Tripped Reactor Coolant Pumps.Caused by Procedural Deficiency | | | 05000346/LER-1980-002, Forwards LER 80-002/03L-0 | Forwards LER 80-002/03L-0 | | | 05000346/LER-1980-002-03, /03L-0:on 800103,after Actuating of Safety Features Actuation Sys Level 2,demin Water Valve DW68318 Did Not Indicate Closed & Monitor Light Did Not Indicate Properly.Caused by Maladjusted Position Indicator Switch | /03L-0:on 800103,after Actuating of Safety Features Actuation Sys Level 2,demin Water Valve DW68318 Did Not Indicate Closed & Monitor Light Did Not Indicate Properly.Caused by Maladjusted Position Indicator Switch | | | 05000346/LER-1980-003-03, /03L-0:on 800103,during Auxiliary Feedwater Pump Test,Pump l-1 Was Declared Inoperable.Caused by Improperly Adjusted Slip Clutch Between Governor Manual Speed Adjustment Shaft & Remotely Controlled Speed Changer Motion | /03L-0:on 800103,during Auxiliary Feedwater Pump Test,Pump l-1 Was Declared Inoperable.Caused by Improperly Adjusted Slip Clutch Between Governor Manual Speed Adjustment Shaft & Remotely Controlled Speed Changer Motion | | | 05000346/LER-1980-003, Forwards LER 80-003/03L-0 | Forwards LER 80-003/03L-0 | | | 05000346/LER-1980-004-03, /03L-0:on 800107,control Rod 5-11 Absolute Position Indication Declared Inoperable Due to Fluctuating Signals.Possibly Caused by Isolation of Position Indication Cabling & Electrical Penetration | /03L-0:on 800107,control Rod 5-11 Absolute Position Indication Declared Inoperable Due to Fluctuating Signals.Possibly Caused by Isolation of Position Indication Cabling & Electrical Penetration | | | 05000346/LER-1980-004, Forwards LER 80-004/03L-0 | Forwards LER 80-004/03L-0 | | | 05000346/LER-1980-005, Forwards LER 80-005/03L-0 | Forwards LER 80-005/03L-0 | | | 05000346/LER-1980-005-03, /03L-0:on 800110,Tech Spec Late Date Passed W/O Performance of Boric Acid Flowpath Heat Tracing Weekly Test. Caused by Known Deficiency in Design of Sys Resulting in Inability to Maintain Min Temp Necessary During Startup | /03L-0:on 800110,Tech Spec Late Date Passed W/O Performance of Boric Acid Flowpath Heat Tracing Weekly Test. Caused by Known Deficiency in Design of Sys Resulting in Inability to Maintain Min Temp Necessary During Startup | | | 05000346/LER-1980-006-03, /03L-0:on 800112,found Fiberglass Insulation Stuffed Into Open Wall Ventilator Between Water Treatment Bldg & Svc Water Valve Room,Causing Fire Damper to Be Inoperable.Figerglass Removed | /03L-0:on 800112,found Fiberglass Insulation Stuffed Into Open Wall Ventilator Between Water Treatment Bldg & Svc Water Valve Room,Causing Fire Damper to Be Inoperable.Figerglass Removed | | | 05000346/LER-1980-006, Forwards LER 80-006/03L-0 | Forwards LER 80-006/03L-0 | | | 05000346/LER-1980-007, Forwards LER 80-007/03L-0 | Forwards LER 80-007/03L-0 | | | 05000346/LER-1980-007-03, /03L-0:on 800116,ref Position Verification for Group 5,rod 11,was Made 1-h & 40 Minutes Late.Caused by Operator Oversight Due to Lack of Adequate Reminder Sys. Multiple Timer Sys Will Prevent Recurrence | /03L-0:on 800116,ref Position Verification for Group 5,rod 11,was Made 1-h & 40 Minutes Late.Caused by Operator Oversight Due to Lack of Adequate Reminder Sys. Multiple Timer Sys Will Prevent Recurrence | | | 05000346/LER-1980-008-03, Gap Discovered in Wall Where Five two-inch Conduits Go from Electrical Penetration Room 2 to Cable room.Six-inch Gap Around Ventilation Duct Also Found.Caused by Improper Initial Installation | Gap Discovered in Wall Where Five two-inch Conduits Go from Electrical Penetration Room 2 to Cable room.Six-inch Gap Around Ventilation Duct Also Found.Caused by Improper Initial Installation | | | 05000346/LER-1980-008, Forwards Revised LER 80-008/03L-1 | Forwards Revised LER 80-008/03L-1 | | | 05000346/LER-1980-009, Forwards LER 80-009/03L-0 | Forwards LER 80-009/03L-0 | | | 05000346/LER-1980-009-03, /03L-0:on 800122,discovered That NI-7 Indication on Computer Group 38 Was Reading Less than Heat Balance Power,Putting NI-7 Below Instrumentation Operability Limit Line.Caused by Extremely Tight Calibr Band at 100% Power | /03L-0:on 800122,discovered That NI-7 Indication on Computer Group 38 Was Reading Less than Heat Balance Power,Putting NI-7 Below Instrumentation Operability Limit Line.Caused by Extremely Tight Calibr Band at 100% Power | | | 05000346/LER-1980-010-01, /01T-0:on 800214,reanalysis of RCS Pipe Restraints Per IE Insp Rept 50-346/79-23 Revealed Design Deficiency on Two Reactor Coolant Hot Leg Pipe Whip Restraints at Top of Each RCS Hot Leg.Caused by Design Error | /01T-0:on 800214,reanalysis of RCS Pipe Restraints Per IE Insp Rept 50-346/79-23 Revealed Design Deficiency on Two Reactor Coolant Hot Leg Pipe Whip Restraints at Top of Each RCS Hot Leg.Caused by Design Error | | | 05000346/LER-1980-010, Forwards LER 80-010/01T-0 | Forwards LER 80-010/01T-0 | | | 05000346/LER-1980-011, Forwards LER 80-011/03L-0 | Forwards LER 80-011/03L-0 | | | 05000346/LER-1980-011-03, /03L-0:on 800131,during Normal Operation, Operations Personnel Received Half Trip on Steam & Feedwater Rupture Control Sys Channels 1/3.Caused by Spurious Trip from +25 Volt Dc Power Supply PS03 in Sglic Channel 1 | /03L-0:on 800131,during Normal Operation, Operations Personnel Received Half Trip on Steam & Feedwater Rupture Control Sys Channels 1/3.Caused by Spurious Trip from +25 Volt Dc Power Supply PS03 in Sglic Channel 1 | | | 05000346/LER-1980-012-03, /03L-0:on 800201,operator Noticed Loss of Control Room Position Indication for Letdown Cooler Isolation Valve MU2A.Caused by Design Deficiency.Apparently,Someone Brushed Up Against Disconnect Breaker Switch.Switch Reposition | /03L-0:on 800201,operator Noticed Loss of Control Room Position Indication for Letdown Cooler Isolation Valve MU2A.Caused by Design Deficiency.Apparently,Someone Brushed Up Against Disconnect Breaker Switch.Switch Repositioned | | | 05000346/LER-1980-012, Forwards LER 80-012/03L-0 | Forwards LER 80-012/03L-0 | | | 05000346/LER-1980-013, Forwards LER 80-013/03L-0 | Forwards LER 80-013/03L-0 | | | 05000346/LER-1980-013-03, /03L-0:on 800208,w/reactor Startup in Progress, Personnel Noted Control Rod 5-11 Absolute Position Indication Was Not Responding.Caused by Blown Fuse F14 in Position Ref Panel | /03L-0:on 800208,w/reactor Startup in Progress, Personnel Noted Control Rod 5-11 Absolute Position Indication Was Not Responding.Caused by Blown Fuse F14 in Position Ref Panel | | | 05000346/LER-1980-014, Forwards LER 80-014/03L-0 | Forwards LER 80-014/03L-0 | | | 05000346/LER-1980-014-03, /03L-0:on 800208,pressurizer Sample Sys Containment Isolation Valve RC240B Failed to Close Twice. Caused by Improper Torque Switch Setting & Stripped Screw on Closing Contactor.Settings Readjusted & Switch Replaced | /03L-0:on 800208,pressurizer Sample Sys Containment Isolation Valve RC240B Failed to Close Twice. Caused by Improper Torque Switch Setting & Stripped Screw on Closing Contactor.Settings Readjusted & Switch Replaced | | | 05000346/LER-1980-015, Forwards LER 80-015/03L-0 | Forwards LER 80-015/03L-0 | | | 05000346/LER-1980-015-03, /03L-0:on 800210,during Normal Startup,Control Rod 5-11 Absolute Position Indication Declared Inoperable.Caused by Numerous Asymmetric Rod Alarms.Data from Current Failure Evaluated | /03L-0:on 800210,during Normal Startup,Control Rod 5-11 Absolute Position Indication Declared Inoperable.Caused by Numerous Asymmetric Rod Alarms.Data from Current Failure Evaluated | | | 05000346/LER-1980-016, Forwards LER 80-016/03L-0 | Forwards LER 80-016/03L-0 | | | 05000346/LER-1980-016-03, /03L-0:on 800213,while Reviewing Station Log,Shift Foreman Discovered That Containment Airlock Seal Leakage Test Had Not Been Performed After Last Entry Into Containment During Startup.Caused by Procedural Inadequacy | /03L-0:on 800213,while Reviewing Station Log,Shift Foreman Discovered That Containment Airlock Seal Leakage Test Had Not Been Performed After Last Entry Into Containment During Startup.Caused by Procedural Inadequacy | | | 05000346/LER-1980-017-03, /03L-0:on 800217,operations Personnel Noted That Safety Features Actuation Sys Channel 3 Borated Water Storage Tank Level Indication Was Six Feet Higher than Other Meters.Caused by Freezing of Transmitter Sensing Line | /03L-0:on 800217,operations Personnel Noted That Safety Features Actuation Sys Channel 3 Borated Water Storage Tank Level Indication Was Six Feet Higher than Other Meters.Caused by Freezing of Transmitter Sensing Line | | | 05000346/LER-1980-017, Forwards LER 80-017/03L-0 | Forwards LER 80-017/03L-0 | | | 05000346/LER-1980-018-03, /03L-0:on 800226,safety Features Actuation Sys Channel 3 Borated Water Storatge Tank Level Indication Was Discovered Reading Four Feet Higher than Other Three Channels.Caused by Inadequate Design of Freeze Protection | /03L-0:on 800226,safety Features Actuation Sys Channel 3 Borated Water Storatge Tank Level Indication Was Discovered Reading Four Feet Higher than Other Three Channels.Caused by Inadequate Design of Freeze Protection | | | 05000346/LER-1980-018, Forwards LER 80-018/03L-0 | Forwards LER 80-018/03L-0 | | | 05000346/LER-1980-019, Forwards LER 80-019/01T-0 | Forwards LER 80-019/01T-0 | | | 05000346/LER-1980-019-01, /01T-0:on 800325 Reactor Flux/Flow Trip Setpoints Were Not Verified to Be Properly Reset within 4-h of Manual Shutdown of Rcp.Caused by Attention Given to Feedwater Swings.Trip Setpoints Verified Later | /01T-0:on 800325 Reactor Flux/Flow Trip Setpoints Were Not Verified to Be Properly Reset within 4-h of Manual Shutdown of Rcp.Caused by Attention Given to Feedwater Swings.Trip Setpoints Verified Later | | | 05000346/LER-1980-020, Forwards LER 80-020/03L-0 | Forwards LER 80-020/03L-0 | | | 05000346/LER-1980-020-03, /03L-0:on 800306,control Operator Noted No Control Room Indication for Containment Vacuum Relief Isolation Valve CV5072.Caused by Breaker BE1139 Being Closed,Probably Resulting from Someone Bumping Into Breaker | /03L-0:on 800306,control Operator Noted No Control Room Indication for Containment Vacuum Relief Isolation Valve CV5072.Caused by Breaker BE1139 Being Closed,Probably Resulting from Someone Bumping Into Breaker | | | 05000346/LER-1980-021, Forwards LER 80-021/03L-0 | Forwards LER 80-021/03L-0 | | | 05000346/LER-1980-021-03, /03L-0:on 800313,during Diesel Fire Protection Pump Weekly Test,Pump Could Not Be Stopped W/Control Button. Once Stopped,Pump Could Not Be Started.Cause Not Determined by Scheme Check.Retrial of Pump Proved Successful | /03L-0:on 800313,during Diesel Fire Protection Pump Weekly Test,Pump Could Not Be Stopped W/Control Button. Once Stopped,Pump Could Not Be Started.Cause Not Determined by Scheme Check.Retrial of Pump Proved Successful | | | 05000346/LER-1980-022-03, /03L-0:on 800317,operations Personnel Noticed Loss of Control Room Indication for Containment Dihydrogen Analyzer 2 Discharge Line Valve CV5010E.Caused by Const Personnel Accidentally Opening Breaker | /03L-0:on 800317,operations Personnel Noticed Loss of Control Room Indication for Containment Dihydrogen Analyzer 2 Discharge Line Valve CV5010E.Caused by Const Personnel Accidentally Opening Breaker | | | 05000346/LER-1980-022, Forwards LER 80-022/03L-0 | Forwards LER 80-022/03L-0 | | | 05000346/LER-1980-023, Forwards LER 80-023/03L-0 | Forwards LER 80-023/03L-0 | | | 05000346/LER-1980-023-03, /03L-0:on 800327,discovered That Control Rod Groups 3 & 4 Were Moving in on Their Own.Group 3 Was 0% Withdrawn.Group 4 Was 90% Withdrawn.Caused by Component Failure.Component Replaced | /03L-0:on 800327,discovered That Control Rod Groups 3 & 4 Were Moving in on Their Own.Group 3 Was 0% Withdrawn.Group 4 Was 90% Withdrawn.Caused by Component Failure.Component Replaced | | | 05000346/LER-1980-024-03, /03L-0:on 800327,following Normally Initiated Reactor Trip,Auxiliary Feed Pump Turbine 1-2 Main Steam Isolation Valve MS-107 Closed.Cause Unknown.Further Investigation of Valve & Operator Will Be Pursued | /03L-0:on 800327,following Normally Initiated Reactor Trip,Auxiliary Feed Pump Turbine 1-2 Main Steam Isolation Valve MS-107 Closed.Cause Unknown.Further Investigation of Valve & Operator Will Be Pursued | | | 05000346/LER-1980-024, Forwards LER 80-024/03L-0 | Forwards LER 80-024/03L-0 | | | 05000346/LER-1980-025-03, /03X-1:on 800330,control Rod Group 5,rod 11 Absolute Position Indication Declared Inoperable.Caused by Fluctuating Signals Resulting in Numerous Asymmetric Rod Alarms Due to Defective Reed Switch Assemblies | /03X-1:on 800330,control Rod Group 5,rod 11 Absolute Position Indication Declared Inoperable.Caused by Fluctuating Signals Resulting in Numerous Asymmetric Rod Alarms Due to Defective Reed Switch Assemblies | | | 05000346/LER-1980-025, Forwards LER 80-025/03X-1 | Forwards LER 80-025/03X-1 | |
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