LER-1982-068, /03L-0:on 821220,core Imbalance Vs Core Power Limit Computer Alarm C963 Inoperable.Caused by Mistake in Alarm Subroutine.Alarm Statement Corrected So Limits & Value for Imbalance Scaled Same |
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NRCIOkM 366 U.S. NUCLEAR REGULATC~;Y COMMISSION (7-77)
LICENSEE EVENT REPORT CONTROL BLOCK: l l
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8 60 61 DOCKET NUMBER 68 69 EVENT DATE 74 75 REPORT DATE 80 EVENT DESCRIPTION AND PROB ABLE CONSEQUENCES h l (NP-33-82-87) on 12/20/82, it was determined that the Core Imbalance vs. Core Power l
O 2 10 l a I l Limit Computec Alarm, C963, was inoperable. This invoked Tech Spec Surveillance Re-l 1014l lquirement 4.2.1 which requires increased surveillance of the axial power imbalance l
lwith the computer alarm inoperable. There was no danger to the health and safety of l.
o 3 Ithe public or station personnel. The function of computer alarm C963 is to assure thel O s l 0 l 7 l l operator that imbalance is maintained within its limits. With C963 inoperable, only l
l O 1a ] l increased surveillance is required.
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l N1 33 34 35 36 37 40 48 42 43 44 47 CAUSE DESCRIPTION AND CORRECTIVE ACTIONS h IiI0llThe cause was a mistake in the alarm subroutine. The value for imbalance was in deci-l l mal form and was being compared to the limit which was in a percent form. On 12/20/82l i i l
lapproximately 30 minutes after the problem was discovered, the alarm statement was l
,,,7, lcorrected so that the limits and the value for imbalance were scaled the same. Other l i a l computer alarms which are used to reduce surveillance requirements were verified to be; i 4 operable. 80 7
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7 8 9 11 12 80 LOSS OF OR DAMAGE TO FACtLITY Q TYPE
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TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-33-82-87 DATE OF EVENT: December 20, 1982 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE:
Computer Alarm C963, Core Imbalance vs.
Core Power Limit was discovered to be inoperable Conditions Prior to Occurrence: The unit was in Mode 1, with Power (MWT) = 2740 and Load (Gross MWE) = 923 Description of Occurrence: During the running of Surveillance Test ST 5033.03, Incore Instrument Channel Calibration, the computer alarm C963 could not be alarmed by the method. described in the procedure. At first it was thought that the test method was incorrect. After an investigation of the software, it was found on December 20, 1982 that the value for imbalance was in decimal form whereas the limits were in a' percent form j
(i.e., the value for imbalance was a factor of 100 smaller than the limits). Therefore, the alarm was inoperable.
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l As per Technical Specification Surveillance Requirement 4.2.1, if the alarm is inoperable, increased surveillance was required.
Designation of Apparent Cause of Occurrence: The cause of the event was due to a software mistake in the alarm subroutine.
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Analysis of Occurrence: There was no danger to the health and safety of the public or station personnel. The function of computer alarm C963 is to assurc the operators that imbalance is maintained within its limits.
With the computer alarm C963 inoperable, only increased surveillance is l
required. During the time computer alarm C963 was inoperable, the plant did not experience any adverse conditions. Also imbalance was checked once per shift with no indications of the value to be outside the limits.
Also, imbalance is monitored by the Reactor Protection System (flux-aflux-flow) which was not exceeded.
Corrective Action
Approximately one half hour after the problem was discovered, a Station Programmer, under the direction of a Technical l
Services Engineer, changed the alarm statement for the computer alarm C963 so that the limits and the value for imbalance were scaled the same.
Babcock and Wilcox was notified, and they are producing a Software Change l
Notice (SCN).
Other computer alarms which are used to reduce surveillance requirements l
were verified to be operable. Also, these computer alarms will be func-tionally tested when Technical Specifications require program changes.
In l
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the future, these computer alarms will be qualitatively checked for operability on a shift basis.
Failure Data: There have been no previous occurrences.
LER #82-068
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| 05000346/LER-1982-001-01, /01X-2:on 820113,borated Water Storage Tank Temp Higher than Initial Conditions Assumed.Caused by Lack of Administrative Restrictions on Storage Tank Temp.Procedure Mods Initiated & Insulation Added | /01X-2:on 820113,borated Water Storage Tank Temp Higher than Initial Conditions Assumed.Caused by Lack of Administrative Restrictions on Storage Tank Temp.Procedure Mods Initiated & Insulation Added | | | 05000346/LER-1982-001, Forwards LER 82-001/01X-1 | Forwards LER 82-001/01X-1 | | | 05000346/LER-1982-002, Forwards LER 82-002/03L-0 | Forwards LER 82-002/03L-0 | | | 05000346/LER-1982-002-03, /03L-0:on 820103,radiation Detector RE2007 on Safety Features Actuation Sys Channel 4 Failed Low.Low Radiation Bistable Tripped & Alarmed.Caused by Fabrication Error in Attaching Shortened Cable Wire | /03L-0:on 820103,radiation Detector RE2007 on Safety Features Actuation Sys Channel 4 Failed Low.Low Radiation Bistable Tripped & Alarmed.Caused by Fabrication Error in Attaching Shortened Cable Wire | | | 05000346/LER-1982-003, Forwards LER 82-003/03L-0 | Forwards LER 82-003/03L-0 | | | 05000346/LER-1982-003-03, /03L-0:on 820208 & 10,door 400 Which Forms Part of Negative Pressure Boundary for Spent Fuel Pool Emergency Ventilation Sys Found Open.Caused by Faulty Door Closure Mechanism.Maint Order Issued for Corrective Action | /03L-0:on 820208 & 10,door 400 Which Forms Part of Negative Pressure Boundary for Spent Fuel Pool Emergency Ventilation Sys Found Open.Caused by Faulty Door Closure Mechanism.Maint Order Issued for Corrective Action | | | 05000346/LER-1982-004, Forwards LER 82-004/03L-1 | Forwards LER 82-004/03L-1 | | | 05000346/LER-1982-004-03, /03L-0:on 820122,door 108 to Detergent Waste Drain Tank & Pump Room Found Open.Caused by Worker Disregarding Sign on Door.New Signs Will Be Added to Elaborate Requirement to Close Door | /03L-0:on 820122,door 108 to Detergent Waste Drain Tank & Pump Room Found Open.Caused by Worker Disregarding Sign on Door.New Signs Will Be Added to Elaborate Requirement to Close Door | | | 05000346/LER-1982-005-03, /03L-0:on 820126,RE 2007,containment Area Radiation Control Monitor to Safety Features Actuation Sys Channel 4 Failed Low.Exact Cause Unknown.New Detector Placed in Svc.Failed Detector Returned to Vendor | /03L-0:on 820126,RE 2007,containment Area Radiation Control Monitor to Safety Features Actuation Sys Channel 4 Failed Low.Exact Cause Unknown.New Detector Placed in Svc.Failed Detector Returned to Vendor | | | 05000346/LER-1982-005, Forwards LER 82-005/03L-0 | Forwards LER 82-005/03L-0 | | | 05000346/LER-1982-006-03, /03L-1:on 820126,determination of Reportability Made Re 820113 Event.During Attempt to Start Component Cooling Water Pump 1-1,breaker AC113 Would Not Close.Caused by Worn Rack in Mechanism.Mechanism Replaced | /03L-1:on 820126,determination of Reportability Made Re 820113 Event.During Attempt to Start Component Cooling Water Pump 1-1,breaker AC113 Would Not Close.Caused by Worn Rack in Mechanism.Mechanism Replaced | | | 05000346/LER-1982-006, Forwards LER 82-006/03L-1 | Forwards LER 82-006/03L-1 | | | 05000346/LER-1982-007-03, /03L-0:on 820201,spent Fuel Pool Water Level Dropped Below Tech Spec Limit.Caused by Deficiency in Sp 1104.42.Procedure mod,T-6087,added Requiring Siphon Breaker on Temporary Line Used to Move Water | /03L-0:on 820201,spent Fuel Pool Water Level Dropped Below Tech Spec Limit.Caused by Deficiency in Sp 1104.42.Procedure mod,T-6087,added Requiring Siphon Breaker on Temporary Line Used to Move Water | | | 05000346/LER-1982-007, Forwards LER 82-007/03L-0 | Forwards LER 82-007/03L-0 | | | 05000346/LER-1982-008-03, /03X-1:on 820208,mechanical Penetration Room Pressure Gauge PDI-5000 Failed,Rendering Emergency Ventilation Sys Train 1-1 Inoperable.Caused by Ice Buildup on Transmitter Vent Line.Ice Removed | /03X-1:on 820208,mechanical Penetration Room Pressure Gauge PDI-5000 Failed,Rendering Emergency Ventilation Sys Train 1-1 Inoperable.Caused by Ice Buildup on Transmitter Vent Line.Ice Removed | | | 05000346/LER-1982-008, Forwards LER 82-008/03L-0 | Forwards LER 82-008/03L-0 | | | 05000346/LER-1982-009-03, /03L-0:on 820209 & 0217,door 107 Was Found Blocked Open.Cause of First Incident Was Design Deficiency.Second Finding Caused by Personnel Error.Orientation & Requalification Classes & Contractor Classes Initiated | /03L-0:on 820209 & 0217,door 107 Was Found Blocked Open.Cause of First Incident Was Design Deficiency.Second Finding Caused by Personnel Error.Orientation & Requalification Classes & Contractor Classes Initiated | | | 05000346/LER-1982-009, Forwards LER 82-009/03L-0 | Forwards LER 82-009/03L-0 | | | 05000346/LER-1982-010-03, /03L-0:on 820218,during Periodic Test PT 5186.01, Valve Dh 10 Found Unlocked & Out of Position,Causing Loss of One Possible long-term Boron Dilution Flowpath.Caused by Operator Errors.Operators & Supervisors Counseled | /03L-0:on 820218,during Periodic Test PT 5186.01, Valve Dh 10 Found Unlocked & Out of Position,Causing Loss of One Possible long-term Boron Dilution Flowpath.Caused by Operator Errors.Operators & Supervisors Counseled | | | 05000346/LER-1982-010, Forwards LER 82-010/03L-0 | Forwards LER 82-010/03L-0 | | | 05000346/LER-1982-011-03, /03L-0:on 820225,while Performing Control Rod Exercising Test,Control Rod 5-2 Dropped to 0% Withdrawn. Caused by Blown Fuse in Transfer Switch Module Assembly B Phase.Blown Fuse Replaced | /03L-0:on 820225,while Performing Control Rod Exercising Test,Control Rod 5-2 Dropped to 0% Withdrawn. Caused by Blown Fuse in Transfer Switch Module Assembly B Phase.Blown Fuse Replaced | | | 05000346/LER-1982-011, Forwards LER 82-011/03L-0 | Forwards LER 82-011/03L-0 | | | 05000346/LER-1982-012-01, /01T-0:on 820314,during Final Stages of RCS Cooldown,Water Injected to Make Up for RCS Inventory Shrinkage Was Lower than Expected Boron Concentration.Caused by Personnel & Procedure Error.Procedure Modified | /01T-0:on 820314,during Final Stages of RCS Cooldown,Water Injected to Make Up for RCS Inventory Shrinkage Was Lower than Expected Boron Concentration.Caused by Personnel & Procedure Error.Procedure Modified | | | 05000346/LER-1982-012, Forwards LER 82-012/01T-0 | Forwards LER 82-012/01T-0 | | | 05000346/LER-1982-013-03, /03L-0:on 820302,radiation Element Re 2007 in Safety Features Actuation Sys Channel 4 Failed Low.Caused by Broken Wire in Cable Connector in Penetration Box P4LIGX. Connector Reterminated & Detector Replaced | /03L-0:on 820302,radiation Element Re 2007 in Safety Features Actuation Sys Channel 4 Failed Low.Caused by Broken Wire in Cable Connector in Penetration Box P4LIGX. Connector Reterminated & Detector Replaced | | | 05000346/LER-1982-013, Forwards LER 82-013/03L-0 | Forwards LER 82-013/03L-0 | | | 05000346/LER-1982-014-03, /03L-0:on 820311,fire Door 101A Blocked Open by Temporary Hose.Caused by Const Personnel Error During Flush of Level Instrumentation Column.Operator Posted at Door Until Hose Removed | /03L-0:on 820311,fire Door 101A Blocked Open by Temporary Hose.Caused by Const Personnel Error During Flush of Level Instrumentation Column.Operator Posted at Door Until Hose Removed | | | 05000346/LER-1982-014, Forwards LER 82-014/03L-0 | Forwards LER 82-014/03L-0 | | | 05000346/LER-1982-015-03, /03L-0:on 820312,shift Supervisor Failed to Instruct Operators to Start Control Room Ventilation in Recirculation Mode During Routine Maint on Chlorine Detector.Caused by Operator Error | /03L-0:on 820312,shift Supervisor Failed to Instruct Operators to Start Control Room Ventilation in Recirculation Mode During Routine Maint on Chlorine Detector.Caused by Operator Error | | | 05000346/LER-1982-015, Forwards LER 82-015/03L-0 | Forwards LER 82-015/03L-0 | | | 05000346/LER-1982-016, Forwards LER 82-016/03L-0 | Forwards LER 82-016/03L-0 | | | 05000346/LER-1982-017-03, /03L-0:on 820323,valve CS20 Discovered Locked in Wrong Position.Caused by Personnel Error.Shift Operators Retrained on Safety Significance & Implications of Having Locked Valves in Abnormal Positions | /03L-0:on 820323,valve CS20 Discovered Locked in Wrong Position.Caused by Personnel Error.Shift Operators Retrained on Safety Significance & Implications of Having Locked Valves in Abnormal Positions | | | 05000346/LER-1982-017, Forwards LER 82-017/03L-0 | Forwards LER 82-017/03L-0 | | | 05000346/LER-1982-018-03, /03X-1:on 820326,source Range Detector NI-2 High Voltage Cable Cut by Const Electrician,Resulting in Loss of One Source Range Indicator.Caused by Problem in Coordinating Work.Cable Reconnected | /03X-1:on 820326,source Range Detector NI-2 High Voltage Cable Cut by Const Electrician,Resulting in Loss of One Source Range Indicator.Caused by Problem in Coordinating Work.Cable Reconnected | | | 05000346/LER-1982-018, Forwards LER 82-018/03L-0 | Forwards LER 82-018/03L-0 | | | 05000346/LER-1982-019-01, /01X-1:on 820419,during Steam Generator Eddy Current Insp,Some Generator Tubes Adjacent to Auxiliary Feedwater Header Showed Potential Interaction W/Header Support Sys.Caused by Collapse of Steam Bubble in Header | /01X-1:on 820419,during Steam Generator Eddy Current Insp,Some Generator Tubes Adjacent to Auxiliary Feedwater Header Showed Potential Interaction W/Header Support Sys.Caused by Collapse of Steam Bubble in Header | | | 05000346/LER-1982-020, Forwards Revised LER 82-020/03X-1 | Forwards Revised LER 82-020/03X-1 | | | 05000346/LER-1982-020-03, Loss of 120 Volt Alternating Current Distribution Panel Y2 Experienced While in Mode 6.Safety Feature Actuation Signal Channel 2 Actuated.Caused by Blown YV2 Inverter Fuse.Fuse Replaced | Loss of 120 Volt Alternating Current Distribution Panel Y2 Experienced While in Mode 6.Safety Feature Actuation Signal Channel 2 Actuated.Caused by Blown YV2 Inverter Fuse.Fuse Replaced | | | 05000346/LER-1982-021-03, /03L-0:on 820505,source Range Audible Indicator Signal Lead Found Disconnected.Lead Disconnected During Test Earlier in Day & Reconnection Not Verified.Caused by Procedure Deficiency.Procedure Rewritten | /03L-0:on 820505,source Range Audible Indicator Signal Lead Found Disconnected.Lead Disconnected During Test Earlier in Day & Reconnection Not Verified.Caused by Procedure Deficiency.Procedure Rewritten | | | 05000346/LER-1982-021, Forwards LER 82-021/03L-0 | Forwards LER 82-021/03L-0 | | | 05000346/LER-1982-022-03, /03L-0:on 820512,fire Barrier Door 302,forming Part of Negative Pressure Boundary for Spent Fuel Pool Area, Found Propped Open.Caused by Personnel Error.Personnel Instructed Re Importance of Obeying Signs | /03L-0:on 820512,fire Barrier Door 302,forming Part of Negative Pressure Boundary for Spent Fuel Pool Area, Found Propped Open.Caused by Personnel Error.Personnel Instructed Re Importance of Obeying Signs | | | 05000346/LER-1982-022, Forwards LER 82-022/03L-0 | Forwards LER 82-022/03L-0 | | | 05000346/LER-1982-023, Forwards LER 82-023/01T-1 | Forwards LER 82-023/01T-1 | | | 05000346/LER-1982-024-03, /03L-0:on 820522,discharge Valve Mu 348 from Boric Acid Pump 1-1 Found in Closed Position.Caused by Personnel Error.Operators Counseled & Maint for Check Valves Reviewed | /03L-0:on 820522,discharge Valve Mu 348 from Boric Acid Pump 1-1 Found in Closed Position.Caused by Personnel Error.Operators Counseled & Maint for Check Valves Reviewed | | | 05000346/LER-1982-024, Forwards LER 82-024/03L-0.Detailed Event Analysis Encl | Forwards LER 82-024/03L-0.Detailed Event Analysis Encl | | | 05000346/LER-1982-025, Forwards LER 82-025/03L-0 | Forwards LER 82-025/03L-0 | | | 05000346/LER-1982-025-03, /03L-0:on 820527,test Interval for Boration Flowpath Heat Trace Test ST 5011.01 Exceeded.Caused by Personnel Error.Event Reviewed W/Responsible Individuals & Memo Issued to Operators | /03L-0:on 820527,test Interval for Boration Flowpath Heat Trace Test ST 5011.01 Exceeded.Caused by Personnel Error.Event Reviewed W/Responsible Individuals & Memo Issued to Operators | | | 05000346/LER-1982-026-03, /03L-0:on 820530 & 0608,fire Door 504 Between Computer Room & Cabinet Room Found Blocked Open.Caused by Personnel Error.Personnel Instructed in Proper Procedure for Blocking fire/safety-related Doors | /03L-0:on 820530 & 0608,fire Door 504 Between Computer Room & Cabinet Room Found Blocked Open.Caused by Personnel Error.Personnel Instructed in Proper Procedure for Blocking fire/safety-related Doors | | | 05000346/LER-1982-026, Forwards LER 82-026/03L-0 | Forwards LER 82-026/03L-0 | | | 05000346/LER-1982-027-03, /03L-0:on 820608,combined Leakage for All Containment Penetration Valves Exceeded Tech Spec Limits. Caused by Component Failure W/Two Valves Failing Due to Misapplication of Seating Matl.Valves Repaired | /03L-0:on 820608,combined Leakage for All Containment Penetration Valves Exceeded Tech Spec Limits. Caused by Component Failure W/Two Valves Failing Due to Misapplication of Seating Matl.Valves Repaired | |
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