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Results
Other: 05000346/LER-1978-115, Forwards LER 78-115/01T-0, 05000346/LER-1978-115-01, /01T-0:on 781127,noted That Station Procedures Failed to Specify Proper Actions in Event of Combined Steam & Feedwater Rupture Control Sys & Safety Features Actuation Sys Actuation, ML19206A426, ML19206A441, ML19263A926, ML19263C911, ML19322C679, ML20062F539
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LER-1978-115, /01T-0:on 781127,noted That Station Procedures Failed to Specify Proper Actions in Event of Combined Steam & Feedwater Rupture Control Sys & Safety Features Actuation Sys Actuation |
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| 3461978115R01 - NRC Website |
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U. S. NUCLEAR IIEGULATtRY COMMISSION NRC FtRM 36G (7 77)
LICENSEE EVENT REPORT CONTROL BLOCK: l l
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61 COCKET NUMBEM EVENT DESCRIPTION AND PROBA8LE CONSEQUENCES h 8
during a meeting to discuss a proposed change to the steam generator levell 10121 l On 11/27/78, it was determined that station procedurc{s l setpoints for the Auxiliary Feedwater System, io l3 j d
g l f ailed to specify the proper actions for the event of a combined Steam and Fee water o,
i System (SFAS) actuation j o,,,, l Rupture Control System (SFRCS) and Saf ety Features Actuat on d as per Tech Spec 4
l 0 {6 l l This inadequacy of administative controls is being reporte The special 120 inch level setpoint is only required in the unlikely j
j o l 7 l l 6.9.1.8(1).
(NP-32-78-12 ) g l cvent of an SFRCS actuation and a small Reactor Coolant System break.
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g l The unique requirement of a 120 inch level setpoint for a ecmbined SFRCS and SFAS Modifications to all station procedures related to
_J l 3 l 3 l l actuation was not recognized.
l l SFRCS actuation are being prepared.
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Jacqtte LinEettf 01ter PHOE DVR 78-176 NAYF OF PHEPARER
TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-32-78-12 DATE OF EVENT: November 27, 1978 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE: Procedure inadequacy if a small Reactor Coolant Sys-tem (RCS) leak occurred during a Steam and Feedwater Rupture Control System (SFRCS) actuation Conditions Prior to Occurrence: The unit was in Mode 1, with Power (MWI) = 2250, and Load (MWE) = 720.
Description of Occurrence: On November 27, 1978, Toledo Edison and Babcock and i
Wilcox personnel met to discuss a proposed change to the steam generator level setpoints for the Auxiliary Feedwater System, which provides feedwater when the SFRCS is actuated.
A steam generator level of about 35 inches was determined to be adequate in all cases of SFRCS actuation except when an RCS leak in the "small break" category An SFRCS actuation in conjunction with a small break requires a 120 inch occurs.
level setpoint.
With the present control configuration,120 inch steam generator level setpoint is automatically obtained in all cases of SFRCS actuation.
In order to minimize the effects of the cooldown following auxiliary feedwater injection, station emergency procedures direct the operator to take manual control of the auxiliary feedwater and maintain a lower level. The procedures do not tell the operator to leave the auxiliary feedwater in automatic (" Auto Essential") if a small RCS break occurs with the SFRCS actuation, or to return to automatic if a small break occurs af ter SFRCS
(
actuation. Actuation of the Safety Fe'atures Actuation System (SFAS) Incident Level 2 is considered to be the indication of a small break.
Failure of the procedures to specify the proper actions for the event of a combined SFRCS and SFAS actuation is being reported as per Technical Specification 6.9.1.8(1).
Designation of Apparent Cause of Occurrence: The procedural inadequacy occurred because the unique requirement of a 120 inch steam generator level setpoint for a SFRCS and SFAS actuation was not recognized until the proposed change in setpoints was investigated.
e Analysis of Occurrence: There was no danger to the health and safety of the public or to unit personnel. The 120 inch steam generator level 'setpoint is only required
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in the unlikely event of an SFRCS actuation and a small RCS' break.
i I
LER #78-115 I
e.
TOLEDO EDISON COMPA!N DAVIS-BESSE NUCLEAR POWER STATION UNIT OI.E PAGE 2 SUPPLEMENTAL INFORMATION FOR LER NP-32-78-12 Modifications to all station procedures related to SFRCS actua-
Corrective Action
Tha modifications will require the operator to leave tion are being prepared.
(or return) the auxiliary feedwater controls in automatic in the event of an SFAS Incident. Level 2 actuation occurring with an SFRCS actuation.
No previous discoveries of procedure errors due to unrecognized Failure Dcta:
safety analysis assumptions have been made.
LER #78-115
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| 05000346/LER-1978-002-03, /03L-0:on 780103,control Rod Group 5 Rod 12 Absolute Position Indication Declared Inoperable.Caused by Component Failure of Absolute Position Indicator Reed Switch.Switch Replaced | /03L-0:on 780103,control Rod Group 5 Rod 12 Absolute Position Indication Declared Inoperable.Caused by Component Failure of Absolute Position Indicator Reed Switch.Switch Replaced | | | 05000346/LER-1978-002, Forwards LER 78-002/03L-0 | Forwards LER 78-002/03L-0 | | | 05000346/LER-1978-003-03, /03L-0:on 780103,unidentified RCS Leakage Greater than 1,66 Gallon Per Minute.Caused by Loose Packing on Valve DH2735.Valve Repacked & Stroked | /03L-0:on 780103,unidentified RCS Leakage Greater than 1,66 Gallon Per Minute.Caused by Loose Packing on Valve DH2735.Valve Repacked & Stroked | | | 05000346/LER-1978-003, Forwards LER 78-003/03L-0 | Forwards LER 78-003/03L-0 | | | 05000346/LER-1978-004, Forwards LER 78-004/03L-0 | Forwards LER 78-004/03L-0 | | | 05000346/LER-1978-004-03, /03L-0:on 780105,inlet Balancing Dampers to Emergency Ventilation Sys Fans 1-1 & 1-2 Found Closed.Cause Unknown.Dampers Returned to Balance Position & Locknut Tightened | /03L-0:on 780105,inlet Balancing Dampers to Emergency Ventilation Sys Fans 1-1 & 1-2 Found Closed.Cause Unknown.Dampers Returned to Balance Position & Locknut Tightened | | | 05000346/LER-1978-005-03, /03L-0:on 780106,auxiliary Feed Pump Turbine 1-1 Speed Control Lost & Declared Inoperable.Caused by Short Circuits & Blown Fuses Due to Design Deficiency.Higher Current Rated Relays Installed & Circuit Modified | /03L-0:on 780106,auxiliary Feed Pump Turbine 1-1 Speed Control Lost & Declared Inoperable.Caused by Short Circuits & Blown Fuses Due to Design Deficiency.Higher Current Rated Relays Installed & Circuit Modified | | | 05000346/LER-1978-005, Forwards LER 78-005/03L-0 | Forwards LER 78-005/03L-0 | | | 05000346/LER-1978-006-03, /03L-0:on 780107,computer Alarm Indicated That Steam & Feedwater Rupture Control Sys Steam Generator to Feedwater Differential Pressure Channel 1 Had Tripped.Caused by Component Failure.Input Buffer 1-3 in Channel 1 Replaced | /03L-0:on 780107,computer Alarm Indicated That Steam & Feedwater Rupture Control Sys Steam Generator to Feedwater Differential Pressure Channel 1 Had Tripped.Caused by Component Failure.Input Buffer 1-3 in Channel 1 Replaced | | | 05000346/LER-1978-006, Forwards LER 78-006/03L-0 | Forwards LER 78-006/03L-0 | | | 05000346/LER-1978-007-03, /03L-0:on 780109,during Monthly Surveillance Test ST 5081.01,diesel Generator 1-1 Tripped on High Crankcase Pressure.Caused by Dirty Crankcase Vent Oil Collector.Vent Oil Collector Disassembled & Cleaned | /03L-0:on 780109,during Monthly Surveillance Test ST 5081.01,diesel Generator 1-1 Tripped on High Crankcase Pressure.Caused by Dirty Crankcase Vent Oil Collector.Vent Oil Collector Disassembled & Cleaned | | | 05000346/LER-1978-007, Forwards LER 78-007/03L-0 | Forwards LER 78-007/03L-0 | | | 05000346/LER-1978-008-03, /03L-0:on 780112,both Containment Spray Pumps Found Inoperable.Caused by Personnel Error.Spray Pump Circuit Breakers re-energized | /03L-0:on 780112,both Containment Spray Pumps Found Inoperable.Caused by Personnel Error.Spray Pump Circuit Breakers re-energized | | | 05000346/LER-1978-008, Forwards LER 78-008/03L-0 | Forwards LER 78-008/03L-0 | | | 05000346/LER-1978-009-03, /03L-0:on 780112,component Cooling Water Heat Exchanger 1-1 Outlet Isolation Valve SW 1424 Declared Inoperable.Caused by Component Failure.Solenoid Valve in Control Scheme Found Burned Out.Unit Removed | /03L-0:on 780112,component Cooling Water Heat Exchanger 1-1 Outlet Isolation Valve SW 1424 Declared Inoperable.Caused by Component Failure.Solenoid Valve in Control Scheme Found Burned Out.Unit Removed | | | 05000346/LER-1978-009, Forwards LER 78-009/03L-0 | Forwards LER 78-009/03L-0 | | | 05000346/LER-1978-010-03, /03L-0:on 780115, Reactor Coolant Pump Monitor on Channel 1 Found Out of Tolerance & Reactor Protection Sys Declared Inoperable.Caused by Defective Module.New Module Calibr & Installed | /03L-0:on 780115, Reactor Coolant Pump Monitor on Channel 1 Found Out of Tolerance & Reactor Protection Sys Declared Inoperable.Caused by Defective Module.New Module Calibr & Installed | | | 05000346/LER-1978-010, Forwards LER 78-010/O3L-0 | Forwards LER 78-010/O3L-0 | | | 05000346/LER-1978-011, Forwards LER 78-011/03L-0 | Forwards LER 78-011/03L-0 | | | 05000346/LER-1978-011-03, /03L-0:on 780116,during Surveillance Test,Decay Heat Pump 1-1 Failed to Start.Caused by Fuses in Breaker for Decay Heat Motor Failing to Make Proper Contact.Control Power Fuese Pulled & Reinserted.Pump Returned to Svc | /03L-0:on 780116,during Surveillance Test,Decay Heat Pump 1-1 Failed to Start.Caused by Fuses in Breaker for Decay Heat Motor Failing to Make Proper Contact.Control Power Fuese Pulled & Reinserted.Pump Returned to Svc | | | 05000346/LER-1978-012, Forwards LER 78-012/03L-0 | Forwards LER 78-012/03L-0 | | | 05000346/LER-1978-012-03, /03L-0:on 780124,personnel Airlock Failed Leak Rate Test.Caused by Loose Shaft Seal Due to Routine Use of Personnel & Escape Lock (Exit/Entry to Containment).Shaft Seals Tightened to Prevent Excessive Leakage | /03L-0:on 780124,personnel Airlock Failed Leak Rate Test.Caused by Loose Shaft Seal Due to Routine Use of Personnel & Escape Lock (Exit/Entry to Containment).Shaft Seals Tightened to Prevent Excessive Leakage | | | 05000346/LER-1978-013-03, /03L-0:780119,Cell 32 in Station Battery 1N Electrolyte Specific Gravity Decreased 0.003 Greater than Allowed by Tech Spec 3.8.2.3.Caused by Electrolyte Stratification Due to Low Battery Loading | /03L-0:780119,Cell 32 in Station Battery 1N Electrolyte Specific Gravity Decreased 0.003 Greater than Allowed by Tech Spec 3.8.2.3.Caused by Electrolyte Stratification Due to Low Battery Loading | | | 05000346/LER-1978-013, Forwards LER 78-013/03L-0 | Forwards LER 78-013/03L-0 | | | 05000346/LER-1978-014, Forwards LER 78-014/03L-0 | Forwards LER 78-014/03L-0 | | | 05000346/LER-1978-014-03, /03L-0:on 780123,quandrant Power Tilt in Excess of Steady State & Transient Limits Indicated by Unit Process Computer.Caused by Detector Inadvertently Left Off Scan After Testing.Test Procedure Being Modified | /03L-0:on 780123,quandrant Power Tilt in Excess of Steady State & Transient Limits Indicated by Unit Process Computer.Caused by Detector Inadvertently Left Off Scan After Testing.Test Procedure Being Modified | | | 05000346/LER-1978-015, Forwards LER 78-015/03L-0 | Forwards LER 78-015/03L-0 | | | 05000346/LER-1978-015-03, /03L-0:on 780131,feedwater Steam Generator 1 Channel 2 Pressure Differential Switch Did Not Actuate at Desired Setpoint During Surveillance Test.Caused by Pressure Differential Switch Out of Tolerance | /03L-0:on 780131,feedwater Steam Generator 1 Channel 2 Pressure Differential Switch Did Not Actuate at Desired Setpoint During Surveillance Test.Caused by Pressure Differential Switch Out of Tolerance | | | 05000346/LER-1978-016-03, /03L-1:on 780202,absolute Position Indicator for Group 5,Rod 12,declared Inoperable.Caused by Component Failure in Penetration Area.Containment Conductors Connected to Spare Penetration Connector | /03L-1:on 780202,absolute Position Indicator for Group 5,Rod 12,declared Inoperable.Caused by Component Failure in Penetration Area.Containment Conductors Connected to Spare Penetration Connector | | | 05000346/LER-1978-016, Forwards LER 78-016/03L-1,LER 78-021/03L-1,LER 78-100/03L-1, LER 78-034-03L-1 & LER 78-024/03L-1 | Forwards LER 78-016/03L-1,LER 78-021/03L-1,LER 78-100/03L-1, LER 78-034-03L-1 & LER 78-024/03L-1 | | | 05000346/LER-1978-017, Forwards LER 78-017/03L-0 | Forwards LER 78-017/03L-0 | | | 05000346/LER-1978-017-03, /03L-0:on 780126,all Meteorological Channels Became Inoperable During Blizzard.Caused by Instrumentation Power Loss Due to Tripped Breaker at Meteorological Tower. Breaker Reset on 780128 | /03L-0:on 780126,all Meteorological Channels Became Inoperable During Blizzard.Caused by Instrumentation Power Loss Due to Tripped Breaker at Meteorological Tower. Breaker Reset on 780128 | | | 05000346/LER-1978-018-03, /03L-0:on 780208,diesel Generator 1-1 Making Unusual Noises During Monthly Test.Unusual Noise Traced to Turbocharger.Exact Cause Undetermined.Turbocharger Replaced & Diesel Generator Monthly Test Completed | /03L-0:on 780208,diesel Generator 1-1 Making Unusual Noises During Monthly Test.Unusual Noise Traced to Turbocharger.Exact Cause Undetermined.Turbocharger Replaced & Diesel Generator Monthly Test Completed | | | 05000346/LER-1978-018, Forwards LER 78-018/03L-0 | Forwards LER 78-018/03L-0 | | | 05000346/LER-1978-019-03, /03L-1:on 780210,decay Heat Cooler Outlet Valve DH14A & DH14B Mechanical Stops Found Incorrectly Opened. Caused by Personnel Incorrectly Resetting Stops After Previous Work Completion.Stops Tagged & Records Marked | /03L-1:on 780210,decay Heat Cooler Outlet Valve DH14A & DH14B Mechanical Stops Found Incorrectly Opened. Caused by Personnel Incorrectly Resetting Stops After Previous Work Completion.Stops Tagged & Records Marked | | | 05000346/LER-1978-020, Forwards LER 78-020/03L-0 | Forwards LER 78-020/03L-0 | | | 05000346/LER-1978-020-03, /03L-0:on 780210,reactor Protection Sys Channel 3 Hot Leg Temp String TI-RC3B4 Declared Inoperable.Caused by Loose Wire Connection.Loose Terminal at Temp Element Tightened,Rendering TI-RC3B4 Operable | /03L-0:on 780210,reactor Protection Sys Channel 3 Hot Leg Temp String TI-RC3B4 Declared Inoperable.Caused by Loose Wire Connection.Loose Terminal at Temp Element Tightened,Rendering TI-RC3B4 Operable | | | 05000346/LER-1978-021-03, /03L-1:on 780220,absolute Position Indicator for Control Rod 12 of Group 5 Declared Inoperable.Caused by Component Failure in Penetration Area.Conductors Connected W/Spare Penetration Connectors | /03L-1:on 780220,absolute Position Indicator for Control Rod 12 of Group 5 Declared Inoperable.Caused by Component Failure in Penetration Area.Conductors Connected W/Spare Penetration Connectors | | | 05000346/LER-1978-022-03, /03L-0:on 780223,flow Transmitter FTRC1A3 Found Inoperable.Caused by Defective Flow Transmitter Amplifier. Amplifier Replaced & Flow Transmitter FTRC1A3 Returned to Svc on 780226 | /03L-0:on 780223,flow Transmitter FTRC1A3 Found Inoperable.Caused by Defective Flow Transmitter Amplifier. Amplifier Replaced & Flow Transmitter FTRC1A3 Returned to Svc on 780226 | | | 05000346/LER-1978-022, Forwards LER 78-022/03L-0 | Forwards LER 78-022/03L-0 | | | 05000346/LER-1978-023-03, /03L-0:on 780224,temp Indication for Reactor Protection Sys Channel 2 Spiked Tripping Channel & Shut Down Reactor.Caused by Faulty Connector Due to Dirt on Contacts. Channel 2 Temp String Modules Removed & Connectors Cleaned | /03L-0:on 780224,temp Indication for Reactor Protection Sys Channel 2 Spiked Tripping Channel & Shut Down Reactor.Caused by Faulty Connector Due to Dirt on Contacts. Channel 2 Temp String Modules Removed & Connectors Cleaned | | | 05000346/LER-1978-023, Forwards LER 78-023/03L-0 | Forwards LER 78-023/03L-0 | | | 05000346/LER-1978-024-03, /03L-1:on 780228,MSIV MS-101 Rendered Inoperable to Allow Maint Personnel to Remove Raised Metal on Two of Four Spring Guide Tubes.Cause of Raised Metal Unknown.Metal Filed Down,Valve Closing Time Adjusted & Valve Tested | /03L-1:on 780228,MSIV MS-101 Rendered Inoperable to Allow Maint Personnel to Remove Raised Metal on Two of Four Spring Guide Tubes.Cause of Raised Metal Unknown.Metal Filed Down,Valve Closing Time Adjusted & Valve Tested | | | 05000346/LER-1978-025-03, /03L-0:on 780304,RCS Leakage Found Greater than 1 Gallon Per Minute.Leakage Cause Undetermined.Leakages Processed Through Normal Containment Sump.Unidentified RCS Leakage Reduced Below 1 Gallon Per Minute in 5.5-h | /03L-0:on 780304,RCS Leakage Found Greater than 1 Gallon Per Minute.Leakage Cause Undetermined.Leakages Processed Through Normal Containment Sump.Unidentified RCS Leakage Reduced Below 1 Gallon Per Minute in 5.5-h | | | 05000346/LER-1978-025, Forwards LER 78-025/03L-0 | Forwards LER 78-025/03L-0 | | | 05000346/LER-1978-026, Forwards LER 78-026/03L-0 | Forwards LER 78-026/03L-0 | | | 05000346/LER-1978-026-03, /03L-0:on 780309,radiation Monitor Re 5029 Found Inoperable Due to Low Sample flow.12 Previous Radiation Monitor Inoperabilities Not Reported.Caused by Pump Motor Bearing Seizure Due to High Ambient Temp | /03L-0:on 780309,radiation Monitor Re 5029 Found Inoperable Due to Low Sample flow.12 Previous Radiation Monitor Inoperabilities Not Reported.Caused by Pump Motor Bearing Seizure Due to High Ambient Temp | | | 05000346/LER-1978-027, Forwards LER 78-027/03L-0 | Forwards LER 78-027/03L-0 | | | 05000346/LER-1978-027-03, /03L-0:on 780316,stop Valve AF3870 Failed to Open During Testing.Caused by High Differential Pressure Due to Check Valve AF39 & AF72 Leakage.Motor Operator Initially Not Adjusted for This Pressure,Causing Operator to Torque | /03L-0:on 780316,stop Valve AF3870 Failed to Open During Testing.Caused by High Differential Pressure Due to Check Valve AF39 & AF72 Leakage.Motor Operator Initially Not Adjusted for This Pressure,Causing Operator to Torque Out | | | 05000346/LER-1978-028-03, /03L-0:on 780318,channel 1 Steam Generator 1-1 Declared Inoperable.Caused by Water in Level Transmitter SP09B8 Connecting Box Due to Steam Leak.Connection Box Cleaned & Dried.Waterproof Fitting Will Be Installed | /03L-0:on 780318,channel 1 Steam Generator 1-1 Declared Inoperable.Caused by Water in Level Transmitter SP09B8 Connecting Box Due to Steam Leak.Connection Box Cleaned & Dried.Waterproof Fitting Will Be Installed | |
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