LER-1978-091, /03L-0:on 780815,svc Water Sys Valve Test Notrmed Performed within Required Time Limit.Caused by Personnel Misinterpreting Surveillance Test Schedule.Test Schedule Computer Program Modified,Alleviating Confusion |
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U.S. NUCLE AR REGULAf0WCOMatsgige NRC FORM 3G6 (7 77)
LICENSEE EVENT REPORT CONTROL BLOCK:
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CON'T 68 69 EVENT OATE 74 7S REPORT DATE 80 7
8 60 61 DOCKET NUMBER EVENT DESCR;PTION AND PROBABLE CONSEQUENCES lo 121 l On August 15, 1978 it was discovered y unit personnel that portions of the y
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- - CAUSE DESCRIPTION AND CORRECTIVE ACTIONS h A note to the surveil-l 11 l o l l Personnel error is attributed as the cause of this occurrence.
3 i l lance test schedule statinn that ST 5075.01 Valve Sheets 1-3 must be comnleted wl i, ; 7 y ] interpreted. Surveillance test personnel have modified the cocouter_ program of the l
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DVR.78-141 James P. Itav PHONE:
NAME OF PREPARER
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1 TOLEDO EDISON COMPANY DAVIS-BESSE UNIT ONE NUCLEAR' POWER STATION f
SUPPLEMENTAL INFORMATION FOR LER NP-33-78-108 i
l DATE OF EVENT:;. August'15, 1978 FACILITY: Davis-Besse. Unit 1 IDENTIFICATION OF OCCURRENCE: ' Failure to perform Service Water System Valve Test within allotted limit Conditions Prior to occurrence:
The unit was in Mode 3, with Power (MWT) = 0, and Load (MWE) = 0.
Description of Occurrence: On August 15,.1978, at 1615 hours0.0187 days <br />0.449 hours <br />0.00267 weeks <br />6.145075e-4 months <br />, it was discovered by unit personnel that portions of the Service Water Valve Test ST 5075.01 were not perf ormed within the required time interval.
Technical Speci-fication 4.0.5 refers to the ASME Code which requires all ASME Section XI valves to be tested at least once every 92 days. The maximum allowable extension period 25% of the 92 day frequency which required testing to be completed by August was 14, 1978.
- - Designation of Apparent Cause'of Occurrence: Personnel error is attributed as the cause of this occurrence.
Surveillance test personnel added a note to the surveil-lance test schedule stating that ST 5075.01 Valve Sheets 1-3 must be completed by August 13, 1978 to avoid. violation of Technical Specification 4.0.5.
Operations misinterpreted the note to read valve sheet 3 only and subsequently on August 14, 1978 at 1545 hours0.0179 days <br />0.429 hours <br />0.00255 weeks <br />5.878725e-4 months <br /> 115 days after the last completion of ST.5075.01, the unit was in violation of Technical Specification 4.0.5.
1 Analysis of Occurrence: There was no danger to the health and safety of the public
~or unit personnel. On August 16, 1978 at 1039 hours0.012 days <br />0.289 hours <br />0.00172 weeks <br />3.953395e-4 months <br />, the appropriate service water valves were verified to be within required stroke times. Therefore, the afore-mentioned valves have been in an operable state since the'last date of testing.
Cqrrective Action:
Or. August 16, 1978 at 1039 hours0.012 days <br />0.289 hours <br />0.00172 weeks <br />3.953395e-4 months <br />, Section 8 of ST 5075.01 was completed, thereby, satisfying the surveillance requirements of Technical Specifi-cation 4.0.5.
Also, surveillance test personnel have modified the computer pro-gram of the surveillance test schedule to alleviate any confusion as to which valve sn2ets are to be usec during testing.
Failure Date: The following Licensee Event Reports have been written for personnel errors involving incompletions of Surveillance Tests:
NP-33-77-93, NP-33-77-101.
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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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