LER-1981-030, /03L-0:on 810512,axial Power Imbalance Limit Exceeded.Caused by Procedural Inadequacy.Procedures ST 5042.02 & EP 1205.16 Have Been Modified |
| Event date: |
|
|---|
| Report date: |
|
|---|
| 3461981030R03 - NRC Website |
|
text
. U. S. NUCLE AR 0 E E ULATZ RY COMMISSION 96RC FORM 3G6
'.77)
LICENSEE EVENT REPORT CONTR')L SLOCK: l l
l l
\\
l lh (PLE ASE PRINT OR TYPE ALL CECUIIEJ IZFORMATION) foII) lHlDlBlSl1l@l 0l 0l -] 0l 0] 0] 0] 0l -l 0l 0l@l 4[ 1l 1l 1l 1l@l l
l@
3 8 9 LICENSEE CODE 14 15 LICENSE NuMdEH 23 26 LICENSE TvPE J1 SI LAI 3d 5sRM 11. )@l 0 l 5 l 0 l 01013 l 416 )@l 01511 l 218 l 1 l@l 01 61 01 0C'.*T o i 7
3 60 el CoCnET NUMBER 6d b9 EVEN1 OATE F4 75 REPoHTDATE
- J EVENT OESCRIPTION AND PROS ABLE CONSEQUENCES h lo12l l (NP-33-81-33) On 5/12/81 at 1408 hours0.0163 days <br />0.391 hours <br />0.00233 weeks <br />5.35744e-4 months <br />, the axial power imbalance limit was exceeded. I Prior to the event, reactor I
g l placing the unit in the action statement of T.S. 3.2.1.
g l operators were performing ST 5042.02, " Reactor Coolant System Water Inventory Balance"!
2-1.
There was no dangerl g l due to an earlier seal failure on Reactor Coolant Pump (RCP)
Ito the public or station personnel. The reactor operators restored axial power imbal-1 o e l
g lance within limits within the time allotted by the T.S. action statement.
I 10181 I so OE CO E SLSC E COYPoNENT CODE SUSCoOE S
E 8
IR{Bl@ y @ J @ lZlZjZlZlZlZl@ W @ y @
7 8
9 to II IJ 13 18 19 20 SE QUENTI AL OCCURRENCE REPORT REVISION LE R IVENT YEAR REPORT NO.
CODE TYPE No.
@,a y,Ro I8l1]
l_l l 0l 3l 0l [f_]
l0I3i Lhl I-I LO_J g
_ 21 22 23 24 26 27 23 29 30 31 32 TK A
C c PLANT f T HOURS 22 58 af O FOR >
8.
SUPPL ER MAN ACTuaER lX l g ]34g [JS_ _j g [46Zj@
l 0 l 0l 01 l
lYl@
[N jg l3Zl@ l q 9l 9l q@
Z 3
40 46 42 4
44 47 JJ CAUSE OESCRIPTION AND CORRECTIVE ACTIONS Procedures ST 5042.02 and I
g lThe cause of this occurrence is procedural inadequacy.
as to I EP 1205.16. "RCP and Motor Emergency Procedure" do not provido proper nuideline9 g lwhen ST 5042.02 should be stopped to avoid exceeding axial power imbalance limits dur-l Procedures ST 5042.02 a d EP 1205.16 have been modified.
I g ling a xenon transient.
1 i 4 1
so T
eo A S
% POWE R OTHER STATUS IS O R O'SCoVERY OESCRiPTION [E j@ l 1l 0 l 0l@l NA l
l A{@l Observation by reactor operators l
i s A!TiviTY CO0 TENT AMoVNT OF ACTivlTY @ l LOCATION 07 RELEASE @
RELEASE @D OF RELE ASEgl l
NA l
y NA i 6 so 1
e s to u
44 45 PERSONNEL E XPOSURES NUMBER TYPE
DESCRIPTION
NA l
101010l@[ZJ@l i 7
,tRSONNE aNmLS OEscRiPTiON@
l NuveER 101010 l@l NA i a 80 7
8 9 11 12 LOSS oF OR DaVAGE To FACILITY TYPE
DESCRIPTION
l (Z j@l NA o
so 7
8 9 10 NRC USE ONLY Pust Ci7 l
lllllllllllll$
,7 8 [N. @9)
NA
" 5 4 'I 0 616 e 3 45 8 8
~
a oW PHONE:
DVR 81-067 NAME OF PHEPAHLH
TOLEDG EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL-INFORMATION FOR LER NP-33-81-33
.e DATE OF EVENT: May 12, 1981 FACILITY: Davis-lesse Unit l' IDENTIFICATION OF OCCURRENCE:- Axial Power Imbalance Limitt. Exceeded With Reactor Power Greater Than 40%
Conditions Prior to Occurrence: The unit was in Mode 1, with Power (MWT) = 2031 and Load (Gross NWE) = 680 Description of Occurrence: During the late morning and early afternoon of May'12, 1981, reactor operators were performing ST 5042.02; " Reactor Coolant System (RCS)
Water Inventory Balance" (as required by EP 1202.16, " Reactor Coolant Pump and Motor EmergencyL Procedure") due to a seal failure on Re' actor Coolant Pump (RCP) 2-1 which had occurred ecrlier in the day. Prior to taking RCP 2-1 out of service, reactor power had to be reduced from approximately 100% to 75%. The ensuing xenon transient drove in control rods causing axial power imbalance to go increasingly negative. This effect had to be countered by RCS boration to maintain axial power imbalance within its Technical Specification limits.
In order to perform ST 5042.02 successfully, the RCS has to be maintained as close as possible. to steady state conditions. This entails, among other things, that no additions of boric acid or water to the RCS be made during this test.
At 1402 hours0.0162 days <br />0.389 hours <br />0.00232 weeks <br />5.33461e-4 months <br /> on May-12, 1981, the reactor operators, realizing that axial power im-balance was approaching its Technical Specification limit, stopped ST 5042.02 and injected 30 gallons of boric acid into the RCS. At 1408 hours0.0163 days <br />0.391 hours <br />0.00233 weeks <br />5.35744e-4 months <br /> on May 12, 1981,-the axial power imbalance Technical Specification limit was exceeded. The reactor opera-tors inserted axial power shaping rods (APSRs) 1% (to 24% withdrawn) and, as a result, axial power imbalance was brought back within limits at 1420 hours0.0164 days <br />0.394 hours <br />0.00235 weeks <br />5.4031e-4 months <br /> on May 12, 1981.
Exceeding axial power imbalance limits picced the unit in the action statement of Tech-nical Specification 3.2.1 which states that while in Mode 1 and E 40% rated thermal power, with axial power imbalance exceeding the linits specified on figure 3.2-2a of the Technical Specifications, axial power imbalance must be restored to within its Technical Specification limits within 15 minutes or be in hot standby within 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />.
The total time.that the axial power imbalance Technical Specification limit was ex-ceeded was 12 minutes.
Designation of Apparent Cause of Occurrence: The cause of this occurrence is pro-cedural inadequacy. Procedures EP 1202.16 and ST 5042.02 do not provide proper guidance to the reactor operators during a xenon transient for determining when ST 5042.02 should be performed, how long it should be run, and when, if necessary,
'it should.be't.rminated to avoid exceeding axial power imbalance limits.
EP 1202.16 e
also has conflicting supplementary action steps. Step 1.4.2 suggests running
~
)
ST-5042.02 if idle RCP total seal flow exceeds 2 GPM.
Step 1.4.3 suggests running
'ST 5042.02' unconditionally.
LER #81-030
F p
TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTARY INFORMATION FOR LER NP-33-81-33 PAGE 2 p
Analysis'of Occurrence: There was no danger to the health and safety of'the public cr to a?,ation personnel. The reactor operators took corrective action to reverse the trend of the axial power imbalance before the axial power imbalance technical specif* ation limit was exceeded and as a result of this action, restored axial power Ambalance within limits within the time allotted by the technical specifica-tion action statement. No safety limits were exceeded as maximum axial power in-balance was -6.1%.
The technical specification axial power imbalance limit for.
this power history, power level, and RCP combination is -5.8%.
Corrective Action
At 1402 hours0.0162 days <br />0.389 hours <br />0.00232 weeks <br />5.33461e-4 months <br /> on May 12, 1981, the reactor operators, realizing that axial power imbalance was approaching its Technical Specification limits, in-jected 30 gallons of boric acid into the RCS. After the axial power imbalance limits were exceeded, the operators inserted APSRs 1% (to 24% withdrawn). The combination cf boric acid addition and APSR insertion restored axial power imbalance within limits ct 1420 hours0.0164 days <br />0.394 hours <br />0.00235 weeks <br />5.4031e-4 months <br /> on May 12, 1981.
EP 1202.16 has been modified (per modification T-5561) to add guidance for the reac-tor operators when performing ST 5042.02. ST 5042.02 has been modified (per modifica-tion T-5560) to ;ive reactor operators special guidance when performing this test during xenon transient conditions.
Failure Data: There have been no previous similar events.
LER f 81-030 m
4 o
e w
|
|---|
|
|
| | | Reporting criterion |
|---|
| 05000346/LER-1981-001, Forwards LER 81-001/01X-1 | Forwards LER 81-001/01X-1 | | | 05000346/LER-1981-001-01, /01X-1:on 810107,discovered Contractor Personnel on 801204 Disassembled Restraints Other than Those Requested & Failed to Perform Reassembly in Timely Manner. Caused by Inadequate Procedural Control | /01X-1:on 810107,discovered Contractor Personnel on 801204 Disassembled Restraints Other than Those Requested & Failed to Perform Reassembly in Timely Manner. Caused by Inadequate Procedural Control | | | 05000346/LER-1981-002-03, /03L-0:on 810102,reactor Coolant Pump 1-2 Was Shutdown Due to High Seal Return Temp & Deteriorating Seal Staging & on 810106,pump 2-1 Was Shutdown for Deteriorating Seal Staging.Caused by Seal Degradation.Seals Replaced | /03L-0:on 810102,reactor Coolant Pump 1-2 Was Shutdown Due to High Seal Return Temp & Deteriorating Seal Staging & on 810106,pump 2-1 Was Shutdown for Deteriorating Seal Staging.Caused by Seal Degradation.Seals Replaced | | | 05000346/LER-1981-002, Forwards LER 81-002/03L-0 | Forwards LER 81-002/03L-0 | | | 05000346/LER-1981-003-03, /03L-0:on 810106,breaker HX02B Tripped, de-energizing Bus B Which Reduced Electrical Distribution Less than Tech Specs Required.Caused by Personnel Error. Breakers Restored.Operators Counselled Re Attentiveness | /03L-0:on 810106,breaker HX02B Tripped, de-energizing Bus B Which Reduced Electrical Distribution Less than Tech Specs Required.Caused by Personnel Error. Breakers Restored.Operators Counselled Re Attentiveness | | | 05000346/LER-1981-003, Forwards LER 81-003/03L-0 | Forwards LER 81-003/03L-0 | | | 05000346/LER-1981-004, Forwards LER 81-004/03X-1 | Forwards LER 81-004/03X-1 | | | 05000346/LER-1981-005-03, /03L-0:on 810114,RCS Chloride Concentration Exceeded Tech Spec Limit.Caused by Use of Spotcheck in Cleaning Reactor Coolant Pump Seal Cavities.Instructions Issued for Use of Solvents in RCS | /03L-0:on 810114,RCS Chloride Concentration Exceeded Tech Spec Limit.Caused by Use of Spotcheck in Cleaning Reactor Coolant Pump Seal Cavities.Instructions Issued for Use of Solvents in RCS | | | 05000346/LER-1981-005, Forwards LER 81-005/03L-0 | Forwards LER 81-005/03L-0 | | | 05000346/LER-1981-006-03, /03L-0:on 810119,power Lost to Safety Features Actuation Sys Channel 1 Cabinet.Caused by Blown Supply Fuse from Panel Y-1 Due to Procedure Deficiency.Fuse Replaced & Procedure Modified | /03L-0:on 810119,power Lost to Safety Features Actuation Sys Channel 1 Cabinet.Caused by Blown Supply Fuse from Panel Y-1 Due to Procedure Deficiency.Fuse Replaced & Procedure Modified | | | 05000346/LER-1981-006, Forwards LER 81-006/03L-0 | Forwards LER 81-006/03L-0 | | | 05000346/LER-1981-007, Forwards LER 81-007/03L-0 | Forwards LER 81-007/03L-0 | | | 05000346/LER-1981-007-03, /03L-0:on 810122,door 306 Found Partially Open,So That Spent Fuel Pool Emergency Ventilation Sys Could Not Have Maintained Area at Correct Pressure.Caused by Maladjusted Door Closure.Maint Work Order Issued | /03L-0:on 810122,door 306 Found Partially Open,So That Spent Fuel Pool Emergency Ventilation Sys Could Not Have Maintained Area at Correct Pressure.Caused by Maladjusted Door Closure.Maint Work Order Issued | | | 05000346/LER-1981-008, Forwards LER 81-008/03L-0 | Forwards LER 81-008/03L-0 | | | 05000346/LER-1981-008-03, /03L-0:on 810127,345 Kv Switchyard Bus K Tripped & Locked out,de-energizing Startup Transformer 02.Caused by Action from Directional Ground Current Relay & Charred Phase Lightning Arrestor C on Startup Transformer | /03L-0:on 810127,345 Kv Switchyard Bus K Tripped & Locked out,de-energizing Startup Transformer 02.Caused by Action from Directional Ground Current Relay & Charred Phase Lightning Arrestor C on Startup Transformer | | | 05000346/LER-1981-009-03, /03L-0:on 810128,diesel Generator 1-2 Could Not Be Started W/Left Side Set of Air Start Motors During Diesel Generator Surveillance Test 5081.01.Caused by Failure of One Air Start Motor Due to Broken Solenoid Drive Shaft | /03L-0:on 810128,diesel Generator 1-2 Could Not Be Started W/Left Side Set of Air Start Motors During Diesel Generator Surveillance Test 5081.01.Caused by Failure of One Air Start Motor Due to Broken Solenoid Drive Shaft | | | 05000346/LER-1981-009, Forwards LER 81-009/03L-0 | Forwards LER 81-009/03L-0 | | | 05000346/LER-1981-010, Forwards LER 81-010/03L-0 | Forwards LER 81-010/03L-0 | | | 05000346/LER-1981-010-03, /03L-0:on 810202,MSIV Bypass Valve Ms 100 a Failed to Close.Probably Caused by Component Failure.Actuator Spring Adjusted to Increase Tension Until Valve Would Close | /03L-0:on 810202,MSIV Bypass Valve Ms 100 a Failed to Close.Probably Caused by Component Failure.Actuator Spring Adjusted to Increase Tension Until Valve Would Close | | | 05000346/LER-1981-011, Forwards LER 81-011/03L-0 | Forwards LER 81-011/03L-0 | | | 05000346/LER-1981-011-03, /03L-0:on 810205,post-accident Monitoring Instrument HPI Flow 1-2 Was Declared Inoperable.Caused by Bad Current Buffer.Current Buffer Was Repaired,Recalibr & Reinstalled.Hpi Flow 1-2 Was Returned to Operable Status | /03L-0:on 810205,post-accident Monitoring Instrument HPI Flow 1-2 Was Declared Inoperable.Caused by Bad Current Buffer.Current Buffer Was Repaired,Recalibr & Reinstalled.Hpi Flow 1-2 Was Returned to Operable Status | | | 05000346/LER-1981-012-03, /03L-0:on 810212,control Rod 1-3 Absolute Position Indication Declared Inoperable Due to Fluctuating Signals Causing Asymmetric Rod Alarms.Exact Cause Undetermined,But Absolute Position Indication Leads Picking Up Noise | /03L-0:on 810212,control Rod 1-3 Absolute Position Indication Declared Inoperable Due to Fluctuating Signals Causing Asymmetric Rod Alarms.Exact Cause Undetermined,But Absolute Position Indication Leads Picking Up Noise | | | 05000346/LER-1981-012, Forwards LER 81-012/03L-0 | Forwards LER 81-012/03L-0 | | | 05000346/LER-1981-013-03, /03L-0:on 810218,control Room Normal Ventilation Dampers Tripped Shut Resulting in No Power Available to Chlorine Detector 1 Above Control Room or in Block House. Caused by Failure of 10 Amp Fuse of Circuit Y111 | /03L-0:on 810218,control Room Normal Ventilation Dampers Tripped Shut Resulting in No Power Available to Chlorine Detector 1 Above Control Room or in Block House. Caused by Failure of 10 Amp Fuse of Circuit Y111 | | | 05000346/LER-1981-013, Forwards LER 81-013/03L-0 | Forwards LER 81-013/03L-0 | | | 05000346/LER-1981-014-03, /03X-1:on 810226,decay Heat Valve 64 Would Not Open During Testable ECCS Valves Quarterly Test.Caused by Loose Set Rod Bushing,Allowing Gear Box Set Rod to Move Which Unlocked Limit Switches from Adjusted Position | /03X-1:on 810226,decay Heat Valve 64 Would Not Open During Testable ECCS Valves Quarterly Test.Caused by Loose Set Rod Bushing,Allowing Gear Box Set Rod to Move Which Unlocked Limit Switches from Adjusted Position | | | 05000346/LER-1981-014, Forwards LER 81-014/03X-1 | Forwards LER 81-014/03X-1 | | | 05000346/LER-1981-015-03, /03L-0:on 810227,access Door 107 Found Propped Open from ECCS 2 Pump Room 115 to Miscellaneous Waste Monitor Tank & Pump Room 114.Caused by Failure to Follow Posted Signs While Clearing Odor from Room | /03L-0:on 810227,access Door 107 Found Propped Open from ECCS 2 Pump Room 115 to Miscellaneous Waste Monitor Tank & Pump Room 114.Caused by Failure to Follow Posted Signs While Clearing Odor from Room | | | 05000346/LER-1981-015, Forwards LER 81-015/03L-0 | Forwards LER 81-015/03L-0 | | | 05000346/LER-1981-016, Forwards LER 81-016/03L-0 | Forwards LER 81-016/03L-0 | | | 05000346/LER-1981-016-03, /03L-0:on 810308,dose Equivalent I-131 Level Exceeded Tech Spec Limit.Caused by Gas Leakage Through Fuel Cladding.Levels Monitored | /03L-0:on 810308,dose Equivalent I-131 Level Exceeded Tech Spec Limit.Caused by Gas Leakage Through Fuel Cladding.Levels Monitored | | | 05000346/LER-1981-017-03, /03L-0:on 810309,train 2 Hpi/Low Pressure Injection cross-connect Isolation Valve Dh 63 Would Not Open from Control Room During Quarterly Valve Surveillance Test 5051.13.Caused by Faulty Torque Switch in Valve Operator | /03L-0:on 810309,train 2 Hpi/Low Pressure Injection cross-connect Isolation Valve Dh 63 Would Not Open from Control Room During Quarterly Valve Surveillance Test 5051.13.Caused by Faulty Torque Switch in Valve Operator | | | 05000346/LER-1981-017, Forwards LER 81-017/03L-0 | Forwards LER 81-017/03L-0 | | | 05000346/LER-1981-018-03, /03L-0:on 810322 & 0401,chlorine Detector Ae 5358B Tripped.First Trip Probably Caused by Fouled Detector. Detector Cleaned.Detector & Circuit Board Replaced After Second Failure | /03L-0:on 810322 & 0401,chlorine Detector Ae 5358B Tripped.First Trip Probably Caused by Fouled Detector. Detector Cleaned.Detector & Circuit Board Replaced After Second Failure | | | 05000346/LER-1981-018, Forwards LER 81-018/03L-0 | Forwards LER 81-018/03L-0 | | | 05000346/LER-1981-019-03, /03L-0:on 810323,fluctuating Signals W/Numerous Asymmetric Rod Alarms Received,Resulting in Control Rod 4-7 Absolute Position Indication Inoperability.Probably Caused by Electrical Penetration Module Deficiency | /03L-0:on 810323,fluctuating Signals W/Numerous Asymmetric Rod Alarms Received,Resulting in Control Rod 4-7 Absolute Position Indication Inoperability.Probably Caused by Electrical Penetration Module Deficiency | | | 05000346/LER-1981-019, Forwards LER 81-019/03L-0 | Forwards LER 81-019/03L-0 | | | 05000346/LER-1981-020-03, /03L-0:on 810324,valve CV5011A,on Containment Air Sample Inlet Line to Hydrogen Analyzer,Would Not Stroke Closed W/Monitor Operator.Caused by Badly Worn Tripper in Motor Operator.Tripper Levers Replaced | /03L-0:on 810324,valve CV5011A,on Containment Air Sample Inlet Line to Hydrogen Analyzer,Would Not Stroke Closed W/Monitor Operator.Caused by Badly Worn Tripper in Motor Operator.Tripper Levers Replaced | | | 05000346/LER-1981-020, Forwards LER 81-020/03L-0 | Forwards LER 81-020/03L-0 | | | 05000346/LER-1981-021-03, /03L-0:on 810401,half Trip Occurred from Steam & Feedwater Rupture Control Sys Channel 1 Low Steam Generator Level Trip.Caused by Power Supply Failure.Power Supply Replaced Per Work Order on 810402 | /03L-0:on 810401,half Trip Occurred from Steam & Feedwater Rupture Control Sys Channel 1 Low Steam Generator Level Trip.Caused by Power Supply Failure.Power Supply Replaced Per Work Order on 810402 | | | 05000346/LER-1981-021, Forwards LER 81-021/03L-0 | Forwards LER 81-021/03L-0 | | | 05000346/LER-1981-022, Forwards LER 81-022/03L-0 | Forwards LER 81-022/03L-0 | | | 05000346/LER-1981-022-03, /03L-0:on 810316,NRC Site Inspector Reported Finding Four 0.5-inch Holes Through Control Room Equipment Room East Fire Wall.On 810403,two Holes Found in Wall of Room 427B.Caused by Personnel Error | /03L-0:on 810316,NRC Site Inspector Reported Finding Four 0.5-inch Holes Through Control Room Equipment Room East Fire Wall.On 810403,two Holes Found in Wall of Room 427B.Caused by Personnel Error | | | 05000346/LER-1981-023-03, /03L-1:on 810403,decay Heat Cooler Outlet Valve CC1467 Stroked Closed During Component Cooling Water Monthly Test & Would Not Reopen.Caused by Excessive Wear on Actuator Due to Design Deficiency.Actuator Rebuilt | /03L-1:on 810403,decay Heat Cooler Outlet Valve CC1467 Stroked Closed During Component Cooling Water Monthly Test & Would Not Reopen.Caused by Excessive Wear on Actuator Due to Design Deficiency.Actuator Rebuilt | | | 05000346/LER-1981-023, Forwards LER 81-023/03L-1 | Forwards LER 81-023/03L-1 | | | 05000346/LER-1981-024, Forwards LER 81-024/03L-0 | Forwards LER 81-024/03L-0 | | | 05000346/LER-1981-024-03, /03L-0:on 810418,bus J Was Rapidly Taken Out of Svc W/O Providing for Alternate Power Supply for Decay Heat Pump 1-1.Caused by Personnel Error.Procedure Modified & Operator Informed of Mods | /03L-0:on 810418,bus J Was Rapidly Taken Out of Svc W/O Providing for Alternate Power Supply for Decay Heat Pump 1-1.Caused by Personnel Error.Procedure Modified & Operator Informed of Mods | | | 05000346/LER-1981-025, Forwards LER 81-025/03L-0 | Forwards LER 81-025/03L-0 | | | 05000346/LER-1981-025-03, /03L-0:on 810423,during Review of Safety Tagging Log,Unit Entered Mode 4 W/O Required Two Makeup Pumps Operable.Caused by Personnel Error.Pumps Restored to Operation.Personnel Reinstructed in Procedures | /03L-0:on 810423,during Review of Safety Tagging Log,Unit Entered Mode 4 W/O Required Two Makeup Pumps Operable.Caused by Personnel Error.Pumps Restored to Operation.Personnel Reinstructed in Procedures | | | 05000346/LER-1981-026-03, /03L-0:on 810428,reactor Protection Sys Channel 1 Tripped on Flux/Delta Flux/Flow.Caused by Failure of Flow Differential Pressure Transmitter Primary Power Transformer Shorting to Ground.New Amplifier Installed & Calibr | /03L-0:on 810428,reactor Protection Sys Channel 1 Tripped on Flux/Delta Flux/Flow.Caused by Failure of Flow Differential Pressure Transmitter Primary Power Transformer Shorting to Ground.New Amplifier Installed & Calibr | |
|