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| M80N EDISON PLAZA 300 MADISON AVENUE TOLEDO. OHIO 43652-0001 February 20, 1990 Log No.: BB90 00183 , | | M80N EDISON PLAZA 300 MADISON AVENUE TOLEDO. OHIO 43652-0001 February 20, 1990 Log No.: BB90 00183 , |
| NP33 90 001 Docket No. 50 346 License No. NPF 3 United States Nuclear Regulatory Commission ' | | NP33 90 001 Docket No. 50 346 License No. NPF 3 United States Nuclear Regulatory Commission ' |
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| Davis-Besse Unit _No. 1 015 l010 l0 h l4 l6 91 0 0l0l1 - | | Davis-Besse Unit _No. 1 015 l010 l0 h l4 l6 91 0 0l0l1 - |
| 0 10 012 0F 0l3 veer . = mca anamm Description of Occurrence: | | 0 10 012 0F 0l3 veer . = mca anamm Description of Occurrence: |
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| On January 18, 1990, at 0919 hours, the Reactor Protection System (RPS JC) Channel l 2 was inadvertently bypassed for about one minute during performance of j DB MI-03207, Char.nel Functional Test and Calibration of RCP Monitor Inputs to SFRCS l ACH2 and RPS Channel 2. The RCP Monitor is the Reactor Coolant Pump (RCP) current monitor which senses whether each RCP is on or off and provides an input to the j | | On January 18, 1990, at 0919 hours, the Reactor Protection System (RPS JC) Channel l 2 was inadvertently bypassed for about one minute during performance of j DB MI-03207, Char.nel Functional Test and Calibration of RCP Monitor Inputs to SFRCS l ACH2 and RPS Channel 2. The RCP Monitor is the Reactor Coolant Pump (RCP) current monitor which senses whether each RCP is on or off and provides an input to the j |
| Steam and Feedwater Rupture Control System (SFRCS JB) and RPS. RPS Channel 2 had 1 previously been declared inoperabic on January 12, 1990, when a Reactor Coolant i System (RCS-AB) flow transmitter drifted high out of tolerance. Channel 2 was placed in the tripped condition at that time in compliance with the action statement of Technical Specification 3.3.1.1. Removing the inoperabic channel from the tripped condition to perform this test is a viointion of the action statement. | | Steam and Feedwater Rupture Control System (SFRCS JB) and RPS. RPS Channel 2 had 1 previously been declared inoperabic on January 12, 1990, when a Reactor Coolant i System (RCS-AB) flow transmitter drifted high out of tolerance. Channel 2 was placed in the tripped condition at that time in compliance with the action statement of Technical Specification 3.3.1.1. Removing the inoperabic channel from the tripped condition to perform this test is a viointion of the action statement. |
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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML20046C0661993-07-30030 July 1993 LER 92-009-01:on 920910,deficiencies Discovered During Dynamic Testing of Motor Operated Valves in Response to Generic Ltr 89-10.MOVs W/Deficiencies Modified or Repaired. W/930730 Ltr ML20046B6011993-07-26026 July 1993 LER 93-004-00:on 930428,plant Entered Mode 2 W/Afw Pump Turbine Main Steam Line Crossover Check Valve MS735 in Open Position.Caused by Inappropriate Use of Engineering Judgement.Valve MS735 closed.W/930726 Ltr ML20045D2451993-06-17017 June 1993 LER 93-003-00:on 930520,plant Experienced Trip from Approx & Continuity Between Fuse & Fuseholder Lost,Resulting in Loss of Selected RCS Average Temp Input to Ics.Faulty Fuse Cap & Fuse replaced.W/930617 Ltr ML20044B1681990-07-10010 July 1990 LER 90-002-01:on 900126,reactor Coolant Pump Current Monitor Inputs to Sfrcs ACH1 & Reactor Pressure Sys Channel 1 Experienced Reactor Trip.Probably Caused by Inadequate Test Switches & Isolation plug.W/900710 Ltr ML20043H3201990-06-18018 June 1990 LER 90-010-00:on 900518,station Experienced Inadvertent Safety Features Actuation Signal Level 1-4 Actuation W/Injection of 1,000 Gallons of Borated Water.Caused by Loss of 120-volt Ac Bus Y3.W/900618 Ltr ML20043B5711990-05-25025 May 1990 LER 90-008-00:on 900425,safety Features Actuation Sys Level 1 Actuation Occurred,Resulting in Trip of Containment Radiation Monitors.Caused by High Radiation Fields While Lifting Core Support Assembly.Mod initiated.W/900525 Ltr ML20043B8051990-05-25025 May 1990 LER 90-009-00:on 900426,source-check of Station Vent Radiation Monitors Not Performed Per Tech Spec 3.3.3.10. Caused by Use of Outmoded Light Emitting Dioide as Check Source.Source Check Procedures revised.W/900525 Ltr ML20042F2811990-05-0303 May 1990 LER 90-007-00:on 900403,inadvertent,inconsequential Safety Features Actuation Signal Occured While Defueled.Caused by Incidental Contact W/Monitor in Containment.Temporary Barriers Built Around monitors.W/900503 Ltr ML20042F2791990-05-0303 May 1990 LER 90-006-00:on 900403,station Experienced Safety Features Actuation Sys Levels 1 Through 5 Actuation.Caused by Contact W/Breaker Switch HAAE2 in High Voltage Switchgear Room 2. Meetings Held W/Craft personnel.W/900503 Ltr ML20042E4891990-04-16016 April 1990 LER 90-005-00:on 900314,determined That Some Class 1E Circuits That Pass Through Containment Electrical Penetrations Do Not Have Adequate Backup Fault Protection. Caused by Inadequate Design control.W/900416 Ltr ML20012D0341990-03-19019 March 1990 LER 90-004-00:on 900217,fuel Assembly Moved in Spent Fuel Pool While Emergency Ventilation Inoperable.Caused by Personnel Error.Personnel Involved Counseled & Subj LER Part of Required reading.W/900319 Ltr ML20012C7151990-03-14014 March 1990 LER 90-003-00:on 900212,station Entered Mode 6,refueling,w/o Operable Audible Source Range Indication.Caused by Personnel Error.Individual counseled.W/900314 Ltr ML20012B4851990-03-0606 March 1990 LER 83-039/03X-2:on 830726,discovered That Handwheel for Inner Door of Personnel Airlock in Shut Position & Partially Opened.Caused by Excessive Use of Door During Outages.Door Repaired & Returned to Operable status.W/900306 Ltr ML20011F3831990-02-26026 February 1990 LER 90-002-00:on 900126,reactor Tripped from 73% Power. Caused by Spurious Reactor Coolant Pump Monitor Signal Indicating Only One Pump Running in Each Loop.Pump Seal to Be Replaced During Sixth Refueling outage.W/900226 Ltr ML20006E6861990-02-20020 February 1990 LER 90-001-00:on 900118,reactor Protection Sys Channel 2 Bypassed Temporarily During Performance of DB-MI-03207. Caused by Inadequate Procedure Re Inoperable Channel Removal.Procedure SP1105.02 revised.W/900220 Ltr ML20011E2251990-01-30030 January 1990 LER 86-032-01:on 860802,inadvertent Start of High Pressure Injection Pump 1-2 Occurred.Caused by Open Relay Coil. Failed Relay Replaced & Procedure Change Initiated. W/900130 Ltr ML20005G1091990-01-0909 January 1990 LER 89-015-01:on 891026,concluded That Transmitter Was Out of Tolerance When Reactor Protection Sys Channel 2 Returned to Operable Status on 890924.Caused by leak-by in Instrument Manifold.Transmitter Recalibr successfully.W/900109 Ltr ML20042D4011990-01-0202 January 1990 LER 89-010-01:on 890612,control Room Ventilation Sys Declared Inoperable Due to Compressor High Pressure Trips. Caused by Tripping of Refrigerant Pressure Switch on High Pressure.Switch Reset & Sys retested.W/900102 Ltr ML19354D7361989-12-22022 December 1989 LER 89-018-00:on 891123,hydrogen Dilution Blower 1-1 Casing Drain Line Broke Off at Casing,Declaring Blower Inoperable. Caused by Drain Line Being Accidentally Stepped On.Drain Removed & Pipe Plug installed.W/891222 Ltr ML19332F8951989-12-13013 December 1989 LER 89-017-00:on 891113,containment Spray Pump 1-1 Inadvertently Started During Monthly Functional Test in Safety Features Actuation Sys (Sfas) Channel 1.Caused by Failed Relay in Sfas Channel 3.Relay replaced.W/891213 Ltr ML19332E7521989-12-0404 December 1989 LER 89-016-00:on 890917,unplanned Release of Radioactive Resin to Onsite Settling Basin Occurred.Caused by Personnel Error.Standing Order 89-051 Generated on 890920 to Direct Use of Working Copy of procedures.W/891204 Ltr ML19332D3111989-11-27027 November 1989 LER 89-015-00:on 890924,RCS Flow Transmitter Out of Tolerance When Reactor Protection Sys Channel 2 Returned to Operable Status.Caused by leak-by in Instrument Manifold Seen as Zero Shift.Transmitter recalibr.W/891127 Ltr ML19324C2081989-11-10010 November 1989 LER 89-014-00:on 891011,plastic Sheeting Blocked Off Fire Detectors in Auxiliary Feedwater Pump 1-1 Room & High Voltage Switchgear Room B,Making Fire Detectors Inoperable. Caused by Personnel Oversight.Event reviewed.W/891110 Ltr ML19325D4671989-10-16016 October 1989 LER 89-004-01:on 890411,determined That Circulating Water Line Break Would Result in Loss of Svc Water as Result of Concerns Raised on 890206.Cause Unknown.Standing Order 89-026 in Place to Plug Floor drains.W/891016 Ltr ML19325C8531989-10-13013 October 1989 LER 89-013-00:on 890913,hourly Fire Watch Patrol Exceeded Allowed Interval,Violating Tech Spec 3.7.10,Action a.2. Caused by Personnel Error.Individual Counseled & Event Info Distributed to Fire Watch personnel.W/891013 Ltr ML20024E2591983-08-0101 August 1983 LER 83-033/03L-0:on 830620,fire Detection Zone Reactor Coolant Pump 1-2,containment Level 603 Ft Alarmed & Could Not Be Reset.Caused by Faulty Detector String.Zone Will Be Restored During Next Refueling outage.W/830801 Ltr ML20024B8351983-07-0101 July 1983 LER 83-028/03L-0:on 830603 & 17,fuel Handling Area Radiation Monitors RE8446 & 7 Found Deenergized.Caused by Blown Radiation Monitoring Cabinet Fuse.Fuse replaced.W/830701 Ltr ML20024B0471983-06-21021 June 1983 LER 83-026/03L-0:on 830524,one Half Channel Trip in Steam & Feedwater Rupture Control Sys (Sfrcs) Channel 2 Received. Caused by Component Failure.Input Buffer replaced.W/830621 Ltr ML20024A3621983-06-0909 June 1983 LER 83-024/03L-0:on 830511,while Starting Up from 830510 Reactor Trip,Quadrant Power Tilt in Quadrant Yz Exceeded Tech Spec steady-state Limit.Caused by Inherent Design of B&W NSSS & Negative Moderator Temp coefficient.W/830609 Ltr ML20024A5341983-06-0808 June 1983 LER 83-023/03L-0:on 830510,120-volt Ac Essential Bus Y4 Lost,Resulting in Deenergizing Reactor Protection & Safety Features Actuation Sys Channel 4.Caused by Blown Fuse in Inverter YV4.Power Restored to bus.W/830608 Ltr ML20024A5481983-06-0707 June 1983 Revised LER 83-002/03X-2:on 830115,18,0409,10 & 0510,RCS Dose Equivalent I-131 Exceeded Tech Spec Limit.Caused by Slight Fission Product Leakage Through Fuel Cladding.Level of I-131 monitored.W/830607 Ltr ML20023D9051983-05-26026 May 1983 LER 83-027/03L-0:on 830428,valve RC240B Would Not Close W/O Repeated Signals from Control Room.Caused by Valve Operator Torquing Out Due to Dirty & Improperly Lubricated Stem.Stem Cleaned & Torque Switch reset.W/830526 Ltr ML20023C3241983-05-0505 May 1983 LER 83-016/03L-0:on 830407,determined That Amplifier of Startup Level Transmitter LT-SP9A3 for Steam Generator 1-2 Failed.Caused by Component Failure within Amplifier. Amplifier Replaced ML20023C3021983-05-0505 May 1983 Revised LER 83-002/03X-1:on 830115,RCS Dose Equivalent I-131 Exceeded Tech Spec Limit of 1.0 Uci/Gm.Caused by Leakage of Fission Products Through Fuel cladding.I-131 Monitored Until Level Dropped ML20028E9581983-01-19019 January 1983 LER 82-068/03L-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 ML20028D2291983-01-0707 January 1983 Revised LER 81-045/03X-1:on 810730,after Unit Trip,Three Action Statements Entered.Auxiliary Feedwater Pump 1-2 Did Not Operate Properly.Shield Bldg Integrity Lost When Panel Blown Out.Main Steam Safety Valve Lifted at Low Setpoint ML20028C1231983-01-0303 January 1983 LER 82-064/03L-0:on 821129,decay Heat Cooler Component Cooling Water Outlet Valve on CCW Train 1 Would Not Open. Caused by Mfg Error.Flanged Bearing Missing from Actuator Mounting Plate.Flanged Bearing Installed on 821215 ML20028C3111982-12-30030 December 1982 Revised LER 81-031/03X-6:on 810512,following Reactor Trip, RCS Sample Level Peaked Above Microcurie Limit.Other Iodine Spikes Occurred 810730,0902,1016 & 23 & 1228.Caused by Slight Leakage of Fission Products Through Fuel Cladding ML20028C1971982-12-30030 December 1982 Revised LER 82-045/03X-1:on 820904 & 1203,auxiliary Feedwater Pump 1-1 Suction Valve FW786 Closed for No Apparent Reason W/O Operator Touching Close Button.Cause Unknown.Valve FW786 Reopened Upon Discovery ML20028C2591982-12-30030 December 1982 LER 82-065/03L-0:on 821201,discovered That Control Room Not Placed in Recirculation Mode within 1 H of Ventilation Sys Chlorine Detector Being Taken Out of Svc.On 821203,chlorine Detector Failed.Caused by Personnel Error ML20028B0291982-11-19019 November 1982 LER 82-054/03L-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 ML20028B2281982-11-16016 November 1982 LER 82-053/03L-0:on 821018,half Trip Alarm on Steam & Feedwater Rupture Control Sys Channel 2 Received Due to Failure of Steam Generator Level Instrument Cabinet Channel 2,24-volt Dc Power Supply.Caused by Component Failure ML20027E7891982-11-0404 November 1982 Revised LER 82-052/03X-1:on 820928,reactor Quadrant Power Tilt in Wx Quadrant Exceeded Tech Specs.Caused by Xenon Oscillation Producing Large Negative Imbalance.Control Rod Group 7 Borated Out to Reduce Negative Imbalance ML20027C9551982-10-19019 October 1982 LER 82-049/03L-0:on 820920 & 22,Channels 2 & 3 on Containment post-accident Radiation Monitor Re 4597BA Were Reading High.Caused by Problem in Microprocessor Software. New Set of Software Installed & Faulty Actuator Replaced ML20027C5381982-10-0404 October 1982 LER 82-045/03L-0:on 820904,auxiliary Feedwater Pump 1-1, Suction Valve FW786 Observed Closed for No Apparent Reason W/O Operator Touching Close Button.Cause Unknown. Valve Reopened ML20027A9471982-09-0707 September 1982 LER 82-036/03L-0:on 820808,hole Discovered in Fire Barrier Wall Above Door 309.Caused by Snubber EBD125R43 Penetrating Wall Through Pipe Shell.Hole Left by Workers After Work on Snubbers.Fire Watch Established & Hole Filled ML20052G6651982-05-0707 May 1982 LER 82-020/03L-0:on 820409,while in Mode 6,station Experienced Loss of 120-volt Ac Distribution Panel Y2.Caused by Blown YV2 Inverter Fuse When Short to Ground Occurred During Maint on Control Room Emergency Ventilation Sys ML20052E6231982-04-30030 April 1982 LER 82-019/01T-0:on 820426,some Steam Generator Tubes Adjacent to Auxiliary Feedwater Header Showed Potential Interaction W/Header Support Sys.Header Found Insecurely Fastened & Damaged.Cause & Corrections Being Investigated ML20052E8761982-04-29029 April 1982 LER 82-016/03X-1:on 820312,door 108 Found W/Both Door Closure Mechanisms Broken.Caused by Improper Operation of Door Closure Mechanisms by Personnel.Mechanisms Temporarily Repaired & New Parts Ordered ML20052C4151982-04-23023 April 1982 LER 82-018/03L-0:on 820326,electrician Cut High Voltage Cable on Source Range Detector NI-2,while Working in Containment Penetration Box P1L1L1.Caused by Problem in Coordination of Work Performed.Cut Cable Reconnected 1993-07-30
[Table view] Category:RO)
MONTHYEARML20046C0661993-07-30030 July 1993 LER 92-009-01:on 920910,deficiencies Discovered During Dynamic Testing of Motor Operated Valves in Response to Generic Ltr 89-10.MOVs W/Deficiencies Modified or Repaired. W/930730 Ltr ML20046B6011993-07-26026 July 1993 LER 93-004-00:on 930428,plant Entered Mode 2 W/Afw Pump Turbine Main Steam Line Crossover Check Valve MS735 in Open Position.Caused by Inappropriate Use of Engineering Judgement.Valve MS735 closed.W/930726 Ltr ML20045D2451993-06-17017 June 1993 LER 93-003-00:on 930520,plant Experienced Trip from Approx & Continuity Between Fuse & Fuseholder Lost,Resulting in Loss of Selected RCS Average Temp Input to Ics.Faulty Fuse Cap & Fuse replaced.W/930617 Ltr ML20044B1681990-07-10010 July 1990 LER 90-002-01:on 900126,reactor Coolant Pump Current Monitor Inputs to Sfrcs ACH1 & Reactor Pressure Sys Channel 1 Experienced Reactor Trip.Probably Caused by Inadequate Test Switches & Isolation plug.W/900710 Ltr ML20043H3201990-06-18018 June 1990 LER 90-010-00:on 900518,station Experienced Inadvertent Safety Features Actuation Signal Level 1-4 Actuation W/Injection of 1,000 Gallons of Borated Water.Caused by Loss of 120-volt Ac Bus Y3.W/900618 Ltr ML20043B5711990-05-25025 May 1990 LER 90-008-00:on 900425,safety Features Actuation Sys Level 1 Actuation Occurred,Resulting in Trip of Containment Radiation Monitors.Caused by High Radiation Fields While Lifting Core Support Assembly.Mod initiated.W/900525 Ltr ML20043B8051990-05-25025 May 1990 LER 90-009-00:on 900426,source-check of Station Vent Radiation Monitors Not Performed Per Tech Spec 3.3.3.10. Caused by Use of Outmoded Light Emitting Dioide as Check Source.Source Check Procedures revised.W/900525 Ltr ML20042F2811990-05-0303 May 1990 LER 90-007-00:on 900403,inadvertent,inconsequential Safety Features Actuation Signal Occured While Defueled.Caused by Incidental Contact W/Monitor in Containment.Temporary Barriers Built Around monitors.W/900503 Ltr ML20042F2791990-05-0303 May 1990 LER 90-006-00:on 900403,station Experienced Safety Features Actuation Sys Levels 1 Through 5 Actuation.Caused by Contact W/Breaker Switch HAAE2 in High Voltage Switchgear Room 2. Meetings Held W/Craft personnel.W/900503 Ltr ML20042E4891990-04-16016 April 1990 LER 90-005-00:on 900314,determined That Some Class 1E Circuits That Pass Through Containment Electrical Penetrations Do Not Have Adequate Backup Fault Protection. Caused by Inadequate Design control.W/900416 Ltr ML20012D0341990-03-19019 March 1990 LER 90-004-00:on 900217,fuel Assembly Moved in Spent Fuel Pool While Emergency Ventilation Inoperable.Caused by Personnel Error.Personnel Involved Counseled & Subj LER Part of Required reading.W/900319 Ltr ML20012C7151990-03-14014 March 1990 LER 90-003-00:on 900212,station Entered Mode 6,refueling,w/o Operable Audible Source Range Indication.Caused by Personnel Error.Individual counseled.W/900314 Ltr ML20012B4851990-03-0606 March 1990 LER 83-039/03X-2:on 830726,discovered That Handwheel for Inner Door of Personnel Airlock in Shut Position & Partially Opened.Caused by Excessive Use of Door During Outages.Door Repaired & Returned to Operable status.W/900306 Ltr ML20011F3831990-02-26026 February 1990 LER 90-002-00:on 900126,reactor Tripped from 73% Power. Caused by Spurious Reactor Coolant Pump Monitor Signal Indicating Only One Pump Running in Each Loop.Pump Seal to Be Replaced During Sixth Refueling outage.W/900226 Ltr ML20006E6861990-02-20020 February 1990 LER 90-001-00:on 900118,reactor Protection Sys Channel 2 Bypassed Temporarily During Performance of DB-MI-03207. Caused by Inadequate Procedure Re Inoperable Channel Removal.Procedure SP1105.02 revised.W/900220 Ltr ML20011E2251990-01-30030 January 1990 LER 86-032-01:on 860802,inadvertent Start of High Pressure Injection Pump 1-2 Occurred.Caused by Open Relay Coil. Failed Relay Replaced & Procedure Change Initiated. W/900130 Ltr ML20005G1091990-01-0909 January 1990 LER 89-015-01:on 891026,concluded That Transmitter Was Out of Tolerance When Reactor Protection Sys Channel 2 Returned to Operable Status on 890924.Caused by leak-by in Instrument Manifold.Transmitter Recalibr successfully.W/900109 Ltr ML20042D4011990-01-0202 January 1990 LER 89-010-01:on 890612,control Room Ventilation Sys Declared Inoperable Due to Compressor High Pressure Trips. Caused by Tripping of Refrigerant Pressure Switch on High Pressure.Switch Reset & Sys retested.W/900102 Ltr ML19354D7361989-12-22022 December 1989 LER 89-018-00:on 891123,hydrogen Dilution Blower 1-1 Casing Drain Line Broke Off at Casing,Declaring Blower Inoperable. Caused by Drain Line Being Accidentally Stepped On.Drain Removed & Pipe Plug installed.W/891222 Ltr ML19332F8951989-12-13013 December 1989 LER 89-017-00:on 891113,containment Spray Pump 1-1 Inadvertently Started During Monthly Functional Test in Safety Features Actuation Sys (Sfas) Channel 1.Caused by Failed Relay in Sfas Channel 3.Relay replaced.W/891213 Ltr ML19332E7521989-12-0404 December 1989 LER 89-016-00:on 890917,unplanned Release of Radioactive Resin to Onsite Settling Basin Occurred.Caused by Personnel Error.Standing Order 89-051 Generated on 890920 to Direct Use of Working Copy of procedures.W/891204 Ltr ML19332D3111989-11-27027 November 1989 LER 89-015-00:on 890924,RCS Flow Transmitter Out of Tolerance When Reactor Protection Sys Channel 2 Returned to Operable Status.Caused by leak-by in Instrument Manifold Seen as Zero Shift.Transmitter recalibr.W/891127 Ltr ML19324C2081989-11-10010 November 1989 LER 89-014-00:on 891011,plastic Sheeting Blocked Off Fire Detectors in Auxiliary Feedwater Pump 1-1 Room & High Voltage Switchgear Room B,Making Fire Detectors Inoperable. Caused by Personnel Oversight.Event reviewed.W/891110 Ltr ML19325D4671989-10-16016 October 1989 LER 89-004-01:on 890411,determined That Circulating Water Line Break Would Result in Loss of Svc Water as Result of Concerns Raised on 890206.Cause Unknown.Standing Order 89-026 in Place to Plug Floor drains.W/891016 Ltr ML19325C8531989-10-13013 October 1989 LER 89-013-00:on 890913,hourly Fire Watch Patrol Exceeded Allowed Interval,Violating Tech Spec 3.7.10,Action a.2. Caused by Personnel Error.Individual Counseled & Event Info Distributed to Fire Watch personnel.W/891013 Ltr ML20024E2591983-08-0101 August 1983 LER 83-033/03L-0:on 830620,fire Detection Zone Reactor Coolant Pump 1-2,containment Level 603 Ft Alarmed & Could Not Be Reset.Caused by Faulty Detector String.Zone Will Be Restored During Next Refueling outage.W/830801 Ltr ML20024B8351983-07-0101 July 1983 LER 83-028/03L-0:on 830603 & 17,fuel Handling Area Radiation Monitors RE8446 & 7 Found Deenergized.Caused by Blown Radiation Monitoring Cabinet Fuse.Fuse replaced.W/830701 Ltr ML20024B0471983-06-21021 June 1983 LER 83-026/03L-0:on 830524,one Half Channel Trip in Steam & Feedwater Rupture Control Sys (Sfrcs) Channel 2 Received. Caused by Component Failure.Input Buffer replaced.W/830621 Ltr ML20024A3621983-06-0909 June 1983 LER 83-024/03L-0:on 830511,while Starting Up from 830510 Reactor Trip,Quadrant Power Tilt in Quadrant Yz Exceeded Tech Spec steady-state Limit.Caused by Inherent Design of B&W NSSS & Negative Moderator Temp coefficient.W/830609 Ltr ML20024A5341983-06-0808 June 1983 LER 83-023/03L-0:on 830510,120-volt Ac Essential Bus Y4 Lost,Resulting in Deenergizing Reactor Protection & Safety Features Actuation Sys Channel 4.Caused by Blown Fuse in Inverter YV4.Power Restored to bus.W/830608 Ltr ML20024A5481983-06-0707 June 1983 Revised LER 83-002/03X-2:on 830115,18,0409,10 & 0510,RCS Dose Equivalent I-131 Exceeded Tech Spec Limit.Caused by Slight Fission Product Leakage Through Fuel Cladding.Level of I-131 monitored.W/830607 Ltr ML20023D9051983-05-26026 May 1983 LER 83-027/03L-0:on 830428,valve RC240B Would Not Close W/O Repeated Signals from Control Room.Caused by Valve Operator Torquing Out Due to Dirty & Improperly Lubricated Stem.Stem Cleaned & Torque Switch reset.W/830526 Ltr ML20023C3241983-05-0505 May 1983 LER 83-016/03L-0:on 830407,determined That Amplifier of Startup Level Transmitter LT-SP9A3 for Steam Generator 1-2 Failed.Caused by Component Failure within Amplifier. Amplifier Replaced ML20023C3021983-05-0505 May 1983 Revised LER 83-002/03X-1:on 830115,RCS Dose Equivalent I-131 Exceeded Tech Spec Limit of 1.0 Uci/Gm.Caused by Leakage of Fission Products Through Fuel cladding.I-131 Monitored Until Level Dropped ML20028E9581983-01-19019 January 1983 LER 82-068/03L-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 ML20028D2291983-01-0707 January 1983 Revised LER 81-045/03X-1:on 810730,after Unit Trip,Three Action Statements Entered.Auxiliary Feedwater Pump 1-2 Did Not Operate Properly.Shield Bldg Integrity Lost When Panel Blown Out.Main Steam Safety Valve Lifted at Low Setpoint ML20028C1231983-01-0303 January 1983 LER 82-064/03L-0:on 821129,decay Heat Cooler Component Cooling Water Outlet Valve on CCW Train 1 Would Not Open. Caused by Mfg Error.Flanged Bearing Missing from Actuator Mounting Plate.Flanged Bearing Installed on 821215 ML20028C3111982-12-30030 December 1982 Revised LER 81-031/03X-6:on 810512,following Reactor Trip, RCS Sample Level Peaked Above Microcurie Limit.Other Iodine Spikes Occurred 810730,0902,1016 & 23 & 1228.Caused by Slight Leakage of Fission Products Through Fuel Cladding ML20028C1971982-12-30030 December 1982 Revised LER 82-045/03X-1:on 820904 & 1203,auxiliary Feedwater Pump 1-1 Suction Valve FW786 Closed for No Apparent Reason W/O Operator Touching Close Button.Cause Unknown.Valve FW786 Reopened Upon Discovery ML20028C2591982-12-30030 December 1982 LER 82-065/03L-0:on 821201,discovered That Control Room Not Placed in Recirculation Mode within 1 H of Ventilation Sys Chlorine Detector Being Taken Out of Svc.On 821203,chlorine Detector Failed.Caused by Personnel Error ML20028B0291982-11-19019 November 1982 LER 82-054/03L-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 ML20028B2281982-11-16016 November 1982 LER 82-053/03L-0:on 821018,half Trip Alarm on Steam & Feedwater Rupture Control Sys Channel 2 Received Due to Failure of Steam Generator Level Instrument Cabinet Channel 2,24-volt Dc Power Supply.Caused by Component Failure ML20027E7891982-11-0404 November 1982 Revised LER 82-052/03X-1:on 820928,reactor Quadrant Power Tilt in Wx Quadrant Exceeded Tech Specs.Caused by Xenon Oscillation Producing Large Negative Imbalance.Control Rod Group 7 Borated Out to Reduce Negative Imbalance ML20027C9551982-10-19019 October 1982 LER 82-049/03L-0:on 820920 & 22,Channels 2 & 3 on Containment post-accident Radiation Monitor Re 4597BA Were Reading High.Caused by Problem in Microprocessor Software. New Set of Software Installed & Faulty Actuator Replaced ML20027C5381982-10-0404 October 1982 LER 82-045/03L-0:on 820904,auxiliary Feedwater Pump 1-1, Suction Valve FW786 Observed Closed for No Apparent Reason W/O Operator Touching Close Button.Cause Unknown. Valve Reopened ML20027A9471982-09-0707 September 1982 LER 82-036/03L-0:on 820808,hole Discovered in Fire Barrier Wall Above Door 309.Caused by Snubber EBD125R43 Penetrating Wall Through Pipe Shell.Hole Left by Workers After Work on Snubbers.Fire Watch Established & Hole Filled ML20052G6651982-05-0707 May 1982 LER 82-020/03L-0:on 820409,while in Mode 6,station Experienced Loss of 120-volt Ac Distribution Panel Y2.Caused by Blown YV2 Inverter Fuse When Short to Ground Occurred During Maint on Control Room Emergency Ventilation Sys ML20052E6231982-04-30030 April 1982 LER 82-019/01T-0:on 820426,some Steam Generator Tubes Adjacent to Auxiliary Feedwater Header Showed Potential Interaction W/Header Support Sys.Header Found Insecurely Fastened & Damaged.Cause & Corrections Being Investigated ML20052E8761982-04-29029 April 1982 LER 82-016/03X-1:on 820312,door 108 Found W/Both Door Closure Mechanisms Broken.Caused by Improper Operation of Door Closure Mechanisms by Personnel.Mechanisms Temporarily Repaired & New Parts Ordered ML20052C4151982-04-23023 April 1982 LER 82-018/03L-0:on 820326,electrician Cut High Voltage Cable on Source Range Detector NI-2,while Working in Containment Penetration Box P1L1L1.Caused by Problem in Coordination of Work Performed.Cut Cable Reconnected 1993-07-30
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20217K1231999-10-14014 October 1999 Revised Positions for DBNPS & Pnpp QA Program ML20217D5441999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Davis-Besse Nuclear Power Station.With ML20211R0811999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Davis-Besse Nuclear Power Station,Unit 1.With ML20211B0271999-08-13013 August 1999 SER Accepting Second 10-year Interval Inservice Insp Requests for Relief RR-A16,RR-A17 & RR-B9 for Plant, Unit 1 ML20210Q8541999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Davis-Besse Nuclear Power Station,Unit 1.With ML20209E6231999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Davis-Besse Nuclear Power Station,Unit 1.With ML20195K2871999-06-16016 June 1999 Safety Evaluation Accepting Licensee Response to GL 95-07, Pressure Locking & Thermal Binding of Safety-Related Power-Operated Gate Valves ML20195F4871999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Davis-Besse Nuclear Power Station,Unit 1.With ML20207E8011999-05-19019 May 1999 Non-proprietary Rev 2 to HI-981933, Design & Licensing Rept DBNPS Unit 1 Cask Pit Rack Installation Project ML20207F4351999-05-0404 May 1999 Rev 1 to DBNPS Emergency Preparedness Evaluated Exercise Manual 990504 ML20206M6341999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Davis-Besse Nuclear Station,Unit 1.With ML20205M2931999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Davis-Besse Nuclear Power Station.With ML20207J1461999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Davis-Besse Nuclear Power Station,Unit 1.With ML20199H5931999-01-20020 January 1999 Safety Evaluation Accepting Thermo-Lag Re Ampacity Derating Issues for Plant ML20204J6751998-12-31031 December 1998 1998 Annual Rept for Dbnps,Unit 1,PNPP,Unit 1 & BVPS Units 1 & 2 ML20199E2501998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Davis-Besse Nuclear Power Station,Unit 1.With ML20206B0101998-12-31031 December 1998 1998 Annual Rept for Firstenergy Corp, for Perry Nuclear Power Plant & Davis-Besse Nuclear Power Station.Form 10-K Annual Rept to Us Securities & Exchange Commission for Fiscal Yr Ending 981231,encl ML20205K5781998-12-31031 December 1998 Waterhammer Phenomena in Containment Air Cooler Swss ML20197J3441998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Davis-Besse Nuclear Power Station,Unit 1.With ML20195D0001998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for Davis-Besse Nuclear Power Station,Unit 1.With ML20155B6781998-10-28028 October 1998 Safety Evaluation Accepting Proposed Reduction in Commitment Changes in QA Program Matl Receipt Insp Process ML20154H5801998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Davis-Besse Nuclear Power Station,Unit 1.With ML20151W1611998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for Dbnps.With ML20237E3171998-08-21021 August 1998 ISI Summary Rept of Eleventh Refueling Outage Activities for Davis-Besse Nuclear Power Station ML20237B1681998-07-31031 July 1998 Monthly Operating Rept for July 1998 for Davis-Besse Nuclear Power Station,Unit 1 ML20236U5011998-07-23023 July 1998 Special Rept:On 980624,Unit 1 Site Damaged by Tornado & High Winds.Alert Declared by DBNPS Staff,Dbnps Emergency Response Facilities Activiated & Special Insp Team Deployed to Site by Nrc,As Result of Event ML20236R1441998-07-15015 July 1998 SER Related to Quality Assurance Program Description Changes for Davis-Besse Nuclear Power Station,Unit 1 ML20236N7451998-06-30030 June 1998 Monthly Operating Rept for June 1998 for Davis-Besse Nuclear Power Station,Unit 1 ML20236K3981998-06-30030 June 1998 SER Accepting in Part & Denying in Part Relief Requests from Some of ASME Section XI Requirements as Endorsed by 10CFR50.55a for Containment Insp for Davis-Besse Nuclear Power Station,Unit 1 ML20236K5131998-06-29029 June 1998 Safety Evaluation Accepting Proposed Alternate Emergency Operations Facility Location for Davis-Besse Nuclear Power Station,Unit 1 ML20248F7441998-05-31031 May 1998 Reactor Vessel Working Group,Response to RAI Regarding Reactor Pressure Vessel Integrity ML20249A4121998-05-31031 May 1998 Monthly Operating Rept for May 1998 for Davis-Besse Nuclear Power Station,Unit 1 ML20196B5221998-05-23023 May 1998 10CFR50.59 Summary Rept of Facility Changes,Tests & Experiments Dbnps,Unit 1 for 960602-980523 ML20236E7581998-05-19019 May 1998 Rev 0 to Davis-Besse Unit 1 Cycle 12 Colr ML20236N7501998-04-30030 April 1998 Rev 2 to Monthly Operating Rept for Apr 1998 for Davis-Besse Nuclear Power Station,Unit ML20247F6721998-04-30030 April 1998 Monthly Operating Rept for Apr 1998 for Davis-Bess Nuclear Power Station,Unit 1 ML20249A4141998-04-30030 April 1998 Revised Monthly Operating Rept for Apr 1998 for Davis-Besse Nuclear Power Station,Unit 1 ML20217P8041998-04-0707 April 1998 11RFO OTSG ECT Insp Scope ML20216B4041998-03-31031 March 1998 Monthly Operating Rept for Mar 1998 for Davis-Besse Nuclear Power Station,Unit 1 ML20216C5131998-02-28028 February 1998 Monthly Operating Rept for Feb 1998 for Davis-Besse Nuclear Power Station,Unit 1 ML20202D3721998-01-31031 January 1998 Monthly Operating Rept for Jan 1998 for Davis-Besse Nuclear Power Station,Unit 1 ML20199G6321998-01-26026 January 1998 Rev 1 to Davis-Besse Unit 1,Cycle 11,COLR ML20198R4771998-01-13013 January 1998 SER Approving Second 10-year Interval Inservice Inspection Program Plan Requests for Relief for Davis-Besse Nuclear Power Station,Unit 1 ML20198K7931997-12-31031 December 1997 Monthly Operating Rept for Dec 1997 for Davis-Besse Nuclear Power Station,Unit 1 ML20217K6401997-12-31031 December 1997 1997 Annual Rept First Energy ML20203A3931997-11-30030 November 1997 Monthly Operating Rept for Nov 1997 for Davis-Besse Nuclear Power Plant,Unit 1 ML20198S5371997-10-31031 October 1997 Monthly Operating Rept for Oct 1997 for Davis-Besse Nuclear Power Station ML20217H7701997-09-30030 September 1997 Monthly Operating Rept for Sept 1997 for Davis-Besse Nuclear Power Station,Unit 1 ML20216H3261997-08-31031 August 1997 Monthly Operating Rept for August 1997 for DBNPS ML20217K0241997-07-31031 July 1997 Monthly Operating Rept for Jul 1997 for Davis Besse Nuclear Power Station,Unit 1 1999-09-30
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M80N EDISON PLAZA 300 MADISON AVENUE TOLEDO. OHIO 43652-0001 February 20, 1990 Log No.: BB90 00183 ,
NP33 90 001 Docket No. 50 346 License No. NPF 3 United States Nuclear Regulatory Commission '
Document Control Desk Washington, D. C. 20555 ,
Gentlemen:
LER 90-001 Davis Besse Nuclear Power Station, Unit No. 1 Date of Occurrence - January 18. 1900 l
Enclosed please find Licensee Event Report 90 001, which is being submitted to provide 30 days written notification of the subject occurrence. This LER is being submitted in accordance with 10CFR50.73(a)(2)(1).
Yours truly,
, e L S
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Louis F. Storz Plant Manager Davis Besse Nuclear Power Station LFS/p1f Enclosure cc: Mr. A. Bert Davis Regional Administrator USNRC Region III Mr. Paul Byron DB-1 NRC Sr. Resident Inspector D / ' l 90o226o212 9oo22o j PDR ADOCK o50o0346 S
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TITLE 444 Procedure Indequacy Allowed Inoperable Reactor Protection System Channel to be Bypassed SvtNT DATE LSI Llm NUMBER IS) R8 PORT DAf t (7) OTHER F ACILITIES 30fVOLYtO $4 MONTH DAY YEAR YEAR II, [,"4 :
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~} Tts tu a.v a.w." evecreo suostissroov carts T} NO l l l A=TW:CT ru ,. ,m ,. . ,,.. ,, ,,n e.,w e er-r a , nei On January 18, 1990, at 0919 hours0.0106 days <br />0.255 hours <br />0.00152 weeks <br />3.496795e-4 months <br />, Reactor Protection System (RPS) Channel 2 was bypassed for about one minute during performance of DB MI-03207, the Reactor Coolant Pump (RCP) Monitor Inputs to RPS and Steam and Feedwater Rupture Control System (SFRCS). Since RPS Channel 2 had been declared inoperable and placed in a tripped condition on January 12, 1990, the bypassing is a violation of the action statement of Technical Specification 3.3.1.1. The cause was an inadequate procedure which did not caution against removing an inoperable channel from its tripped condition. Recognizing that the procedure did not provide specific instruction for performing this test on a tripped channel, the RPS Operating Procedure, SP1105.02, was consulted. However, an error in the wiring schematic in the procedure mislead the operator to expect that the channel would not reset. The channel was retripped within one minute of the bypassing. Later the same day, the NRC approved discretionary enforcement which e.11 owed Toledo Edison to remove RPS Channel 2 from the tripped condition for the remainder of the operating cycle. The four procedures which test the RCP monitor inputs to RPS and SFRCS will be changed to prevent removing an inoperable channel from the tripped condition and thus prevent violation of the action statement. Other safety system instrumentation procedures are being evaluated for the need for a similar precautionary statement.
The schematic used as an operator aid in the RPS cabinets and in Operating Procedure, SP1105.02, have been eliminated.
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0 10 012 0F 0l3 veer . = mca anamm Description of Occurrence:
On January 18, 1990, at 0919 hours0.0106 days <br />0.255 hours <br />0.00152 weeks <br />3.496795e-4 months <br />, the Reactor Protection System (RPS JC) Channel l 2 was inadvertently bypassed for about one minute during performance of j DB MI-03207, Char.nel Functional Test and Calibration of RCP Monitor Inputs to SFRCS l ACH2 and RPS Channel 2. The RCP Monitor is the Reactor Coolant Pump (RCP) current monitor which senses whether each RCP is on or off and provides an input to the j
Steam and Feedwater Rupture Control System (SFRCS JB) and RPS. RPS Channel 2 had 1 previously been declared inoperabic on January 12, 1990, when a Reactor Coolant i System (RCS-AB) flow transmitter drifted high out of tolerance. Channel 2 was placed in the tripped condition at that time in compliance with the action statement of Technical Specification 3.3.1.1. Removing the inoperabic channel from the tripped condition to perform this test is a viointion of the action statement.
- This event is reportable as an LER utder 10CFR50.73(a)(2)(1)(3) as a condition prohibited by Technical Specifications.
As part of the review of this event, it was discovered that a similar event occurred on September 23, 1989. In that event, a different flow transmitter failure had caused RPS Channel 2 to be declared inoperable and placed in the tripped condition. During testing, the technician manually bypassed the channel
.mer directions in the procedure.
(ggirent Cause of Occurrence:
ine cause of the action statement violation was an inadequate procedure, DB-MI-03207, which did not provide precautions when performing the test on an inoperable and tripped channel. It should have cautioned against placing such a channel in bypass. Since the procedure did not provide direction for this condition, the RPS Operating Procedure, SP1105.02, was consulted. But due to an error in a schematic in this procedure, the operators were misled to believe that the channel would remain tripped during the test. The schematic incorrectly showed the tie-in point for the manual bypass circuit to be above the reset switch, but in fact, it is below it. Therefore, when the first step in the procedure section of DB MI.03207 was performed, the channel was removed from the tripped condition which violated the action statement.
Annivsis of Occurrence:
Bypassing of the channel places the RPS in a two out of three trip logic rather than a one out of three to trip (with one channel already tripped). Having the inoperable channel bypassed for about one minute has no safety significance. RPS g,o un .v s o.o me o enessasii
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Channel 2 was declared inoperable on January 12, 1990, when an RCS flow transmitter i drifted high out of calibration specifications. The bistables for the other seven s parameters sensed by this RPS Channel were operable. Therefore, when Channel 2 was bypassed, RPS was in a two out of three logic.
The NRC did approve discretionary enforcement later in the day on January 18, 1990, to allow Davis-Besse to reset Channel 2 for the remainder of this operating cycle with the flow transmitter out of tolerance (the Sixth Refueling Outage was scheduled to start February 1, 1990).
Corrective Action:
The four procedures (DB MI 03205, 03206, 03207, and 03208) that test the RCP monitor inputs to the four RPS channels and the four SPRCS channels will be changed to include precautions against removing an inoperable channel from the tripped condition. Thesa procedure changes will be completed before startup from the present refueling outage. Other safety system instrumentation procedures are being evaluated for the netad for a similar precautionary statement.
On February 4, 1990, a decision was made to eliminate the schematic as an operator aid and as an attachment to SP1105.02 (DB-CP 06403). The schematic was removed from the RPS cabinets on February 14, 1990. The change C90 1073 to SP1105.02 (DB 0P 06403) was approved February 15, 1390.
Failure Data:
This is the first report of an inoperable RPS channel being removed from its tripped condition in violation of the action statement. It is now recognized that a similar event occurred on Septen.ber 23, 1989. The only previous report of an inoperable safety system instrumentation function being removed from'the tripped condition in violation of its action statement was LER 87-002. A Safety Features Actuation System (SFAS) Channel I containment radiation trip module was bypassed during post maintenance testing in violation of its action statement. In that
-incident, a technician failed to follow the requirements of the prerequisites of the procedure. The corrective action was counseling of the technician to adhere to procedures. The action would not have prevented the January 18, 1990, event since they involve different causes.
REPORT NO.- NP33 90-001 PCAO No.:90-0022 gge o.. .o .v s oao u se-oe:4-ab4si