Ro:On 920910,discovered That non-TS Hourly Fire Watch, Completed on 920908,improperly Performed,Per Suppl 1 to NRC Bulletin 92-001,resulting in Falsification of Fire Watch Log.Individual Disciplined & Addl Training ProvidedML20118B995 |
Person / Time |
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Site: |
Davis Besse |
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Issue date: |
10/02/1992 |
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From: |
Storz L TOLEDO EDISON CO. |
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To: |
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
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References |
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AB-92-048, AB-92-48, IEB-92-001, IEB-92-1, NP-22-92-08, NP-22-92-8, NUDOCS 9210080246 |
Download: ML20118B995 (2) |
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Category:REPORTABLE OCCURRENCE REPORT (SEE ALSO AO LER)
MONTHYEARML20236U5011998-07-23023 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 ML20115J1121996-07-17017 July 1996 Voluntary Report:On 960430,two Unplanned Starts of Emergency Diesel Generator (EDG) 1-2 Occurred.Caused by Failure to Perform Procedural Step to Verify Power Supply to Electrical Busses D1 & D2.Personnel Counseled ML20071K6881994-07-27027 July 1994 Special Rept:On 940519,pilot Operated Relief Valve Opened for Approx 5 Seconds During Functional Testing of Replacement Reactor Trip Module in Reactor Protection Sys ML20118B9951992-10-0202 October 1992 Ro:On 920910,discovered That non-TS Hourly Fire Watch, Completed on 920908,improperly Performed,Per Suppl 1 to NRC Bulletin 92-001,resulting in Falsification of Fire Watch Log.Individual Disciplined & Addl Training Provided ML20096H0261992-05-19019 May 1992 Special Rept:On 911206,twelve Smoke Detectors in Fire Detection Zone Were Inoperable.Cause Unknown.Detectors Replaced W/Pyrotronics Model DI-6 ML20094L0651992-03-19019 March 1992 Special Rept:On 920204,local Fire Detector Alarm Panel for Fire Detection Zone Was in Trouble Indication Condition. Cause Not Determined.Hourly Fire Watch Patrol Established to Monitor Alarm ML20086K3891991-12-0606 December 1991 Supplement to 910925 Special Rept:On 910830,four Addl Alison Controls,Inc Detectors in Fire Detection Zone RCP-1,RCP-3, RZP-4 & Fdz A208 Failed.Caused by Dust Particles in Sensing Chamber.Subj Detectors Replaced W/Pyrotronics Model DI-6 ML20079F6301991-09-25025 September 1991 Special Rept:On 910818 & 0905,Fire Detection Zone A208 & Instruments Declared Inoperable When Subj Zone Panel Went Into Alarm W/No Indications of Fire.Detector Shipped to Vendor for Troubleshooting & Repair ML20073Q7671991-05-29029 May 1991 Special Rept:On 910415,ionization Type Fire Detector in Fire Detection Zone 235 (Boric Acid Evaporator Room 1-1) Inoperable.Ts 3/4.3.3.8 Entered & Hourly Fire Watch Patrol Established within 1 H ML20072U8091991-01-10010 January 1991 Special Rept:On 910304,electric Fire Pump Removed from Svc for Planned Outage for More than Seven Days.Pump Removed to Replace Existing Controller.Replacement of Controller Accomplished & Electric Fire Pump Returned to Svc ML20058M8561990-08-0606 August 1990 Ro:On 900609 & 11,station Experienced Series of Events Which Lead to Opening of Control Rod Drive Trip Breakers.Caused by Fuse Failure & Mispositioned Control Mode Selector Switch, Respectively.Test Procedure Being Modified ML20246K8931989-07-14014 July 1989 Ro:On 890314,discovered Error in Scheduling & Actual Performance of Surveillance Requirement 4.6.1.3 Re Testing for Personnel & Emergency Air Locks.Caused by Oversight. App J Exemption Request Submitted & Test Interval Changed ML20154C5271988-08-31031 August 1988 Special Rept:On 880722,Tech Spec 3.3.3.3 Violated.Caused by Accelerometers Being Inoperable for More than 30 Days.Mod 88-0060 to Replace Accelerometers Scheduled for Completion by 880915 ML20154M6751988-05-26026 May 1988 Special Rept:On 880419,diesel Fire Pump Removed from Svc for Maint & Declared Inoperable for Longer than Limit Required by Tech Spec Due to Unanticipated Temp Switch Failure.Switch Repaired & Diesel Fire Pump Declared Operable ML20236L4361987-11-0606 November 1987 Special Rept:On 870718,fire Detection Zone FDZ-A208 Declared Inoperable.Caused by Failure of Fire Detector.Hourly Fire Watch Established.Main Work Order Initiated to Repair Detector ML20236S8411987-06-12012 June 1987 Special Rept:On 870513,fire Protection Coordinator Discovered Damage to Fire Barrier Wall in Entrance to Radiation Access Control Area.Probably Caused by Personnel Negligence.Repairs to Wall Should Be Completed by 870731 ML20235B7741987-01-21021 January 1987 RO 07352:on 870121,reactor Tripped from 40% Power.Cause Not Yet Known & All Sys Functioned as Regulated for Reactor Trip ML20076J7391983-06-27027 June 1983 Ro:On 830616,hatches Associated W/Negative Pressure Boundary & Fire Barrier Removed.Notification Satisfies 30-day Requirement.Written Rept Will Be Submitted by 830713 ML20054E1931981-10-16016 October 1981 Telecopy RO Re Max String Error of Pressure/Temp Bistable of Reactor Protection Sys Exceeding Allowable Values of Tech Spec 2.2.1,Table 2.2-1.Event Reported on 811016.Facility Change Request Implemented 1998-07-23
[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 05000346/LER-1998-011, :on 981014,manual Reactor Trip Occurred.Caused by Component Cooling Water Sys Leak.Breaker Being Installed Into D1 Bus cubicle.AACD1 Was Removed from Cubicle1999-09-0303 September 1999
- on 981014,manual Reactor Trip Occurred.Caused by Component Cooling Water Sys Leak.Breaker Being Installed Into D1 Bus cubicle.AACD1 Was Removed from Cubicle
ML20211R0811999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Davis-Besse Nuclear Power Station,Unit 1.With 05000346/LER-1999-003, :on 990727,failure to Perform Engineering Evaluation for Pressurizer Cooldown Rate Exceeding TS Limit Was Noted.Caused by Inadequate Procedural Guidance.Provided Required Reading for Operators.With1999-08-26026 August 1999
- on 990727,failure to Perform Engineering Evaluation for Pressurizer Cooldown Rate Exceeding TS Limit Was Noted.Caused by Inadequate Procedural Guidance.Provided Required Reading for Operators.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 05000346/LER-1998-013, :on 981105,safety Valve Rupture Disks May Induce Excessive Eccentric Loading of Pressurizer Vessel Nozzles.Caused by Failure of RCS Pressure Boundary.Plant Mod Was Implemented in May of 1999.With1999-06-24024 June 1999
- on 981105,safety Valve Rupture Disks May Induce Excessive Eccentric Loading of Pressurizer Vessel Nozzles.Caused by Failure of RCS Pressure Boundary.Plant Mod Was Implemented in May of 1999.With
ML20212H9961999-06-22022 June 1999 Safety Evaluation Supporting Amend 233 to License NPF-3 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 ML20207G6661999-06-0808 June 1999 Safety Evaluation Supporting Amend 232 to License NPF-3 ML20195F4871999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Davis-Besse Nuclear Power Station,Unit 1.With ML20206U7371999-05-19019 May 1999 Safety Evaluation Supporting Amend 231 to License NPF-3 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 05000346/LER-1999-002, :on 990208,both Trains of Emergency Ventilation Sys Were Rendered Inoperable.Caused by Unattended Open Door. Door Was Immediately Closed Upon Discovery.With1999-03-0505 March 1999
- on 990208,both Trains of Emergency Ventilation Sys Were Rendered Inoperable.Caused by Unattended Open Door. Door Was Immediately Closed Upon Discovery.With
ML20207J1461999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Davis-Besse Nuclear Power Station,Unit 1.With ML20206U2441999-02-0909 February 1999 Safety Evaluation Supporting Amend 229 to License NPF-3 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 ML20205K5781998-12-31031 December 1998 Waterhammer Phenomena in Containment Air Cooler Swss 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 ML20197J3441998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Davis-Besse Nuclear Power Station,Unit 1.With 05000346/LER-1998-012, :on 981018,reactor Trip Occurred from Approx 4% Power Due to ARTS Signal.Caused by Inadequate Design Drawing Resulting in Inadequate Procedure.Procedure Revised to Correct Deficiency.With1998-11-17017 November 1998
- on 981018,reactor Trip Occurred from Approx 4% Power Due to ARTS Signal.Caused by Inadequate Design Drawing Resulting in Inadequate Procedure.Procedure Revised to Correct Deficiency.With
05000346/LER-1998-009, :on 980909,RCS Pressurizer Spray Valve Was Not Functional with Two of Eight Body to Bonnet Nuts Missing. Caused by Less than Adequate Matl Separation Work Practices. Bonnet Nuts Replaced.With1998-11-13013 November 1998
- on 980909,RCS Pressurizer Spray Valve Was Not Functional with Two of Eight Body to Bonnet Nuts Missing. Caused by Less than Adequate Matl Separation Work Practices. Bonnet Nuts Replaced.With
05000346/LER-1998-011, :on 981014,manual RT Due to Ccws Leak Was Noted.Caused by Failure of One Letdown Cooler Rupture Disk. All Letdown Cooler Rupture Disks Were Replaced Prior to Plant Restart.With1998-11-13013 November 1998
- on 981014,manual RT Due to Ccws Leak Was Noted.Caused by Failure of One Letdown Cooler Rupture Disk. All Letdown Cooler Rupture Disks Were Replaced Prior to Plant Restart.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 05000346/LER-1998-010, :on 980924,manual Reactor Trip Was Noted.Caused by Misdiagnosed Failure of Main FW Control Valve Solenoid Valve.Faulty Solenoid valve,SVSP6B1,was Replaced & Tested. with1998-10-26026 October 1998
- on 980924,manual Reactor Trip Was Noted.Caused by Misdiagnosed Failure of Main FW Control Valve Solenoid Valve.Faulty Solenoid valve,SVSP6B1,was Replaced & Tested. with
05000346/LER-1998-008, :on 981001,documented Proceduralized Guidance for Initiation of Post LOCA B Dilution Flow Path.Caused by Design Analysis Oversight.Revised Procedures to Provide Active B Dilution Flow Path Guidance.With1998-10-0101 October 1998
- on 981001,documented Proceduralized Guidance for Initiation of Post LOCA B Dilution Flow Path.Caused by Design Analysis Oversight.Revised Procedures to Provide Active B Dilution Flow Path Guidance.With
ML20154H5801998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Davis-Besse Nuclear Power Station,Unit 1.With 05000346/LER-1998-007, :on 980824,CR Humidifier Ductwork Failure Caused Excessive Opening in Positive Pressure Boundary. Caused by Less than Adequate Fabrication.Evaluation of CR Humidifiers Conducted.With1998-09-22022 September 1998
- on 980824,CR Humidifier Ductwork Failure Caused Excessive Opening in Positive Pressure Boundary. Caused by Less than Adequate Fabrication.Evaluation of CR Humidifiers Conducted.With
ML20151W1611998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for Dbnps.With 05000346/LER-1998-006, :on 980624,loss of Offsite Power Was Noted. Caused by Tornado Damage to Switchyard.Tested & Repaired Affected Electrical & Mechanical Equipment Necessary to Restore Two Offsite Power Sources1998-08-21021 August 1998
- on 980624,loss of Offsite Power Was Noted. Caused by Tornado Damage to Switchyard.Tested & Repaired Affected Electrical & Mechanical Equipment Necessary to Restore Two Offsite Power Sources
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 05000346/LER-1998-004, :on 980601,ductwork for Number 2 Control Room Humidifier Found Disconnected from Humidifier.Caused by Less than Adequate Connection at Humidifier Blower Housing. Ductwork Repaired1998-07-13013 July 1998
- on 980601,ductwork for Number 2 Control Room Humidifier Found Disconnected from Humidifier.Caused by Less than Adequate Connection at Humidifier Blower Housing. Ductwork Repaired
05000346/LER-1998-005, :on 980601,both Low Pressure Injection/Dhr Pumps Were Rendered Inoperable During Testing.Caused by Inadequate Self Checking,Communication & Procedure Usage Work Practices.Operations Mgt Reviewed Expectations1998-07-11011 July 1998
- on 980601,both Low Pressure Injection/Dhr Pumps Were Rendered Inoperable During Testing.Caused by Inadequate Self Checking,Communication & Procedure Usage Work Practices.Operations Mgt Reviewed Expectations
ML20236M9411998-07-0707 July 1998 Safety Evaluation Supporting Amend 225 to License NPF-3 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 ML20236N7451998-06-30030 June 1998 Monthly Operating Rept for June 1998 for Davis-Besse Nuclear Power Station,Unit 1 ML20236K4321998-06-30030 June 1998 Safety Evaluation Supporting Amend 224 to License NPF-03 ML20236K5131998-06-29029 June 1998 Safety Evaluation Accepting Proposed Alternate Emergency Operations Facility Location for Davis-Besse Nuclear Power Station,Unit 1 05000346/LER-1998-003, :on 980519,Mode 3 Entry Without Completion of Surveillance Requirement Occurred.Caused by Failure of I&C Technicians to Perform Each Sp as Written or Adherence. Revised Procedure1998-06-18018 June 1998
- on 980519,Mode 3 Entry Without Completion of Surveillance Requirement Occurred.Caused by Failure of I&C Technicians to Perform Each Sp as Written or Adherence. Revised Procedure
1999-09-30
[Table view] |
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% EDlucN A Ce%:m ( nmgp Crap.rq E DSON PL AZ A 3K) MADISON AVL NUE tdt EDO ohio 40U2 UAV NP-33-92-08 AE-92-048 Docket Number 30-346 1,1 cense Numbtr NPF-3 October 2, 1992 United States Nuclear Regulatory Commission Document Control Desk Vashington, D.C.
20555
Subject:
Voluntary Report - Fire Protection Missed Thermo-M g Fire Vatch Gentlemen:
Summary on September 10, 1792, while performing a routine audit of fire watch patrol logs, security personnel discovered that a non-Technical Specification hourly ftre watch, completed on September 8, 1992, was not properly performed. This hourly fire vatch was established an September 1, '.992 as a compensatory measure in response to NRC Bulletin 92-01, a pplement 1, Failure of Thermo-Lag 330 Fire Barrier System to Perform its Specified Fire Endurance Function" (Log Number l-2726), dated August 31, 1992. This is a voluntary report summarizing the citeumstances of this incident.
Discussion on September 10, 1992, as part of an ongoing fire patrol self audit a comparison of fire watch patrol logs to dotr card reader time histories, security personnel discovered that Room 325 (High Voltage Switchgear Room A) was not e.itered from 1706 ui.til 1822 on September 8, 1992, a period of 76 minutes.
This exceeded the 60 +/
15 minute hourly fire watch requirement established in response to NRC Bulletir. 92-01, Supplement 1.
Further investigation revealed that the individual assigned to completing the required fire watch did eot enter Room 325 during the two patrols he performed from 1800 until 2000 on September 8, 1992.
A However, a qualified fire vatch individv3'. enters 3 Room 325 at 1822 and again at 1921 therefore, technically only one lite watnh was missed.
This event was not detected during the hourly reviews of fire watch logs because the fire watch log was incorrectl'/ signed by the individual as if the vatch was properly performed at 1806 and 1906.
Potential Condition Adverse To Quali.ty Report 92-0367 was initiated on September 10, 1992 to address this incident.
I 921008024.2 921002 4
l h PDR ADOCK 05000346
/g S
PDR t
l N
+
Docket Number 50-346 hicense Number NPF-3 Page 2 Toledo Edison has investigated the incident and has coi.cluded that the individual who performed the vatch old not villfully falsify the fire vatch log.
Vhen interviewed, the individual freely tated that he had not entered Room 325 either on the first et second fire watch pattol, lie believed his actions in this area, which consisted of obsersing the door and the area around the door for evidence of a fita and recording the time, vere proper. The individual confitmed that he was trained to enter Room 325 when performing the fire watch but did not proparly recall this training during the September 8, 1992 fire watch patrols.
vas the first performance of the assigned roving fire vatch t oute by the j i hv al since he receivel training on September 1, 1992.
In addition, the to Room 325 was directly on the toute taken to perform the i
iro vatch and, as such, the individual passed by the door to Room 325 during the fire watch patrol.
The individual involved is a security officer and is aware that his duties can be audited and that computer histories are available to assist in audits. Toledo Edison has concluded that the cause of this incident was hurran er 3r and inattention to detail.
This investigation report is available on site ;or NRC review.
Toledo Edison has taken several actions in response to this incident.
Addi*ional tire vatch logs were reviewed and this appears to be an isolated incident.
The individual involved was disciplined.
He also received further training to ensure that he is knowledgeable and able to properly conduct fire vatch duties.
Fire Protection personnel accompanied security personnel on two separate fire watch patrols to ensure the patrols were performed properly.
4 Security personnel vere advised of the incident during shift briefings and the requirerrents of performing proper firevatch duties were reiterated.
Very truly yours, Q
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F. Stor:
Plant Manager MAT /ed G
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11. Davis, Regional Administrator, NRC Region III J. 11. Ilopkins, NRC/NRR DB-1 Senior Project Manager K
P.,
Valton, NRC Region III, DB-1 Resident Inspector l
_