05000346/LER-1982-054-03, /03L-0:on 821021,Door 107 to Radiation Equipment Found Partially Open & Blocked by Hose When Personnel Attempted to Perform Routine Flush on RE-1878.Caused by Personnel Error.Personnel Counseled

/03L-0:on 821021,Door 107 to Radiation Equipment Found Partially Open & Blocked by Hose When Personnel Attempted to Perform Routine Flush on RE-1878.Caused by Personnel Error.Personnel Counseled

ML20028B029
Person / Time
Site:	Davis Besse
Issue date:	11/19/1982
From:	Werner J TOLEDO EDISON CO.
To:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20028B024	List: 05000346/LER-1982-054, Forwards LER 82-054/03L-0 05000346/LER-1982-054-03, /03L-0:on 821021,Door 107 to Radiation Equipment Found Partially Open & Blocked by Hose When Personnel Attempted to Perform Routine Flush on RE-1878.Caused by Personnel Error.Personnel Counseled
References
LER-82-054-03L, LER-82-54-3L, NUDOCS 8211290385
Download: ML20028B029 (3)

LER-1982-054, /03L-0:on 821021,Door 107 to Radiation Equipment Found Partially Open & Blocked by Hose When Personnel Attempted to Perform Routine Flush on RE-1878.Caused by Personnel Error.Personnel Counseled

Event date:
Report date:
3461982054R03 - NRC Website

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60 61 DOCKET NUM8ER 68 69 EVENT DATE 74 75 REPORT DATE 80 EVENT DESCRIPTION AND PROBABLE CONSEQUENCES h l o 121 l(NP-33-82-65) On 10/21/82. I&C personnel oerformed a routine flush on RE-1878 A&B.

I lo l3l I!his procedura involved running an air hose through Door 107 to the REs which was veri-l e

l o 14 I l ied to be fully closed by the I&C personnel before leaving the area at 1015 hours0.0117 days <br />0.282 hours <br />0.00168 weeks <br />3.862075e-4 months <br />.

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I i o i s ; [At 1030 hours0.0119 days <br />0.286 hours <br />0.0017 weeks <br />3.91915e-4 months <br />, an operator found the door partially open and blocked by the hose. Thiq l 016 l lplaced the unit in the action statement of T.S. 3.6.5.2.

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DVR 82-124 NAVE OF PREPARER PHONE:

',o TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-33-82-65 DATE OF EVENT: October 21, 1982 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE: Negative Pressure Boundary Door 107 not fully closed Conditions Prior to Occurrence: The unit was in Mode 1, with Power (MWT) = 2380 and Load (Gross MWE) = 800.

Description of Occurrence: On October 21, 1982, Instrument and Control (I&C) personnel were in the process of performing a routine flush on RE-1878 A&B. This procedure involved running an air hose to the REs through Door 107, the access door from the No. 2 Emergency Core Cooling System (ECCS) Pump Room (Room 115) to the Miscellaneous Waste Monitor Tank Room (Room 114). As this operation takes a couple of hours to complete, the test personnel verified D;or 107 was closed and not blocked by the hose and left the area about 1015 hours0.0117 days <br />0.282 hours <br />0.00168 weeks <br />3.862075e-4 months <br /> to work another job. At about 1030 hours0.0119 days <br />0.286 hours <br />0.0017 weeks <br />3.91915e-4 months <br />, the Primary Equipment Operator found Door 107 partially open and blocked by the hose. This placed the unit in the Action Statement of Technical Specification 3.6.5.2, which requires Door 107 to be closed in order to maintain shield building integrity. The door was immediately closed, thus removing the unit from the Action Statement. The person or persons using Door 107 after the I&C people left the area, and exactly how the hose was moved to hinder door closure, could not be identified.

Designation of Apparent Cause of Occurrence: The cause of this occurrence is personnel error in that whoever went through the door did not verify that the door mechanism fully closed the door.

Analysis of Occurrence: There was no danger to the health and safety of the public or station personnel. With the door slightly open, the effective-ness of the Emergency Ventilation System is reduced, however, a negative pressure would still be created.

Corrective Action

When informed the door was opened, the I&C personnel immediately returned to the area to continually monitor the door. The I&C Maintenance Supervisor and I&C Foreman inspected the test rig and verified that Door 107 would fully close on its own with the hose in place under the corner of the door. All personnel involved were counseled by the Maintenance Engineer that just verifying the door closed is insufficient and that when any hose is run through a door, a continual watch is required on the door. Approval was obtained from Facility Engineering to temporarily utilize an available empty capped pipe in the penetration above the door for future flushes to prevent rece-Ice of the flush hose blocking this door.

In addition, Facility Change quest 79-308 has been initiated to replace this detector with snowplow type which will not require flushing.

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TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-33-82-65 PAGE 2 The root cause of this event is that some people fail to verify that each door they pass through does in fact completely close on its own.

The Station has initiated the following preventive actions to minimize recurrence. General Orientation Training has been upgraded, special memos have been published, specific indoctrination has been given to all work groups, personnel have been disciplined when they have been specifically identified as being responsible, and heavier duty door closures have been installed throughout the plant. A preventive maintenance program to check door closures has been instituted. The Station continues to investigate this problem and will be initiating further corrective actions.

Failure Data: Seven previous occurrences have been reported involving the loss of shield building integrity due to an open door; however, only three of these occurrences, NP-33-82-05 (82-004), NP-33-82-11 (82-009), and NP-33-82-17 (82-016) have been reported within the previous year.

LER #82-054