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

ML20004B190
Person / Time
Site:	Davis Besse
Issue date:	05/22/1981
From:	Kocis R TOLEDO EDISON CO.
To:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20004B188	List: 05000346/LER-1981-025, 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
References
LER-81-025-03L, LER-81-25-3L, NUDOCS 8105270372
Download: ML20004B190 (3)

LER-1981-025, /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

Event date:
Report date:
3461981025R03 - NRC Website

text

U.S. NUCLEAR KEGULATCGY COMMISSl!!N NRC FOriM 3cn (7 77)

LICENSEE EVENT REPORT CONT ROL BLOCK: l l

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60 61 OOCKET NUYS ER 68 69 EVENT DATE 74 75 REPORT OATE 80 7

8 EVENT DESCRIPTION AND PROB ABLE CONSEQUENCES h Jo ja] l (NP-33-81-27) During a review of the Safety Tagging Log prior to entering Mode 3, a i

Shif t Supervisor discovered that Makeup (MU) Pump 2 was still tagged out from 4/11/814 lo tal l l

F5T ! LTherefore, the unit had entered Mode 4 without the required two MU pumps operable.

There was no danger to the public or station personnel. The action statement for TS l lo l5l l l

1 3.1.2.4 requires a shutdown to Hot Standby within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> if less than two MU pumps 0 e 0 7 l are operable when in Modes 1-4.

The second MU pump was restored within 9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br /> of it4 Shutdown.

l g o la l l required operability, and the unit was in Hot 80 DE CODE S BC E COMPONENT CODE SUSCOdE SU E

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3 36 31 40 di 42 43 44 47 CAUSE DESCRIPTION AND CORRECTIVE ACTIONS li l o l l A t' o-ough review of the Safety Tagging Log and an absolute verification of TS requirst-h lijijl ments were not done prior to changing modes. Upon discovery, immediate action was l taken, and the second MU pump was restored by 0445 hours0.00515 days <br />0.124 hours <br />7.357804e-4 weeks <br />1.693225e-4 months <br /> on 4/23/81. The incident was i

, 7 A memorandum was written to all operaf [TTTI I reviewed with the personnel directly involved.

tions personnel to reinforce the necessity for proper procedural verifications.

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TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-33-81-27 DATE OF EVENT: April 23, 1981 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE:

Changed modes without the required number of makeup pumps being operable Conditions Prior to Occurrence: The unit was in Mode 4 with Power (MWT) = 0 and Load (Gross MRE) = 0.

Description of Occurrence: As a precaution for the OTSG tube plugging outage, both makeup pump breakers were racked out and remained racked out until startup proce-dures required the Makeup and Purification' System be put in service to provide seal injection to the reactor coolcnt pumps.

The end of the shift was near and since only one makeup pump was required for this operation, the Makeup and Purification System was made operable with or e makeup pump and the reactor coolant pumps were started. Appropriate log entries were made and startup sequences continued as depicted by the Startup Mode Chec'klist and the Startup Procedure.

. When Mode 4 was approached, the Assistant Shift Supervisor reviewed the Safety Tagging Log for " outstanding items required for entering Mode 4".

He did not notice a tag for the racked out breaker of the second makeup was outstanding and signed off the requirement. The following shift, a second Assistant Shift Supervisor, realizing that the Makeup and Purification System was in service since the reactor coolant pump's had been running and the Safety Tagging Log had been reviewed, ascertained

'that Technical Specification requirements for makeup pumps for Mode 4 had been met and signed off that requirement on the Startup' Checklist. With the Startup Checklist then complete, Mode 4 was attained at 2200 hcurs on April 22, 1981.

The completion of the Startup Checklist for Mode 3 continued which included addi-tional review of the Safety Tagging Log.

The Shift Supervisor making this review noticed the outstarding tag, immediately took the necessary action, and restored the second makeup pump by 0445 hours0.00515 days <br />0.124 hours <br />7.357804e-4 weeks <br />1.693225e-4 months <br /> on April 23, 1981, approximately nine hours after entering Mode 4.

l Designation of Apparent Cause of Occurrence: Events which resulted in this occurrence included errors on the part of two Assistant Shif t Supervisors. A thorough review of the Safety Tagging Log and an absolute verification of Technical Specification require-ments were not done prior to changing modes. Either check would have prevented the occurrence.

LER #81-025

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+

TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-33-81-27 PAGE 2 Analysis of Occurrence: There was no danger to the health and safety of the public or to station personnel. The action statement for Technical Specification 3.1.2.4 rsquires a shutdown to Hot Standby within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> if less than two makeup pumps are operable when in Modes 1-4.

The second makeup pump was restored within 9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br /> of its required operability, and the unit was in Hot Shutdown.

Corrective Action

The second makeup pump was restored as required by 0445 hours0.00515 days <br />0.124 hours <br />7.357804e-4 weeks <br />1.693225e-4 months <br /> on April 23, 1981. The incident was reviewed with the peraonnel directly involved.

A memorandum was written te all operations personnel to reinforce the necessity for proper procedural verifications.

In addition, as secondary cor'rective action, two procedural modifications were prepared to further emphasize the requirement of having both makeup pumps operable as specified in the Technical Specifications.

These procedural hi-lites will further assist in preventing recurrence in the future.

Failure Data: One similar occurrence was reported in Licensee Event Report NP-32-78-13 (78-123).

LER #81-025 i

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