05000346/LER-1982-065-03, /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

/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

ML20028C259
Person / Time
Site:	Davis Besse
Issue date:	12/30/1982
From:	Lang T, Makatura L TOLEDO EDISON CO.
To:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20028C254	List:
References
LER-82-065-03L, LER-82-65-3L, NUDOCS 8301070271
Download: ML20028C259 (3)

LER-1982-065, /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

Event date:
Report date:
3461982065R03 - NRC Website

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60 61 DOCK ET NUMBER 68 69 EVENT DATE 74 75 REPORT DATE 80 EVENT DESCRIPTION AND PROBABLE CONSEQUENCES h l"iiT21 l (NP-33-82-80) On 12/1/82 at 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br />, the Shif t Supervisor discovered that the Con-1 i

l 013 i l trol Room Ventilation System Chlorine Detector AE5358B had been taken out of service l io i4 l lon 11/30/82 without placing the Control Room in the recirculation mode within one hourl IOIs! lper the action statement of Tech Spec 3.3.3.7.

On 12/3/82 at 0845 hours0.00978 days <br />0.235 hours <br />0.0014 weeks <br />3.215225e-4 months <br />, chlorine l

4 10 is l l detector AE5358A failed, placing the unit in the action statement of Tech Spec 3.0.3 l

l 0 l 7 l l since AE5358B was still out of service. There was no danger. Chlorine detectors l

l0isl l located near the chlorine storage tanks were operable.

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u 47 CAUSE DESCRIPTION AND CORRECTIVE ACTIONS lil0llThe cause of the 12/1/82 occurrence is personnel error. The personnel working on l

l AE5358B did not explicitly follow all instructions printed on the MWO. A memo is being 3 i Isent to the responsible personnel. The cause of the 12/3/82 occurrence was a detector l i 2 g l malfunction.

AE5358A was declared operable at 0910 hours0.0105 days <br />0.253 hours <br />0.0015 weeks <br />3.46255e-4 months <br /> on 12/3/82.

AE5358B was l l demonstrated operable on 12/12/82 removing the unit from the action statement.

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TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-33-82-80 DATE OF EVENT: December 1, 1982 FACILITY: Davis-Besse Unit 1 IDENTIFICATION OF OCCURRENCE: Chlorine detectors inoperable Conditions Prior to Occurrence: The unit was in Mode 1, with Power (MWT) = 2741 and Load (Gross MWE) = 909 Description of Occurrence: On December 1, 1982 at 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br />, the Shift Supervisor discovered that Facility Change Request (FCR) work had been initiated which caused the Control Room Ventilation System Chlorine Detector AE5358B to become inoperable. This invoked the action statement of Technical Specification 3.3.3.7, which with one chlorine detector inoperable requires the station to initiate and maintain the Control Room Ventilation System in the recirculation mode within one hour, restore the inoperable detector within 30 days, or be in at least Hot Standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />, and in Cold Shutdown within the follewing 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />. The Shift Supervisor immediately put the Control Room Ventilation System on the recirculation mode following the action statement of Technical Specifi-cation 3.3.3.7.

The plant remained on the recirculation mode until December 12, 1982, when FCR work was completed and operability of AE5358B was demonstrated, removing the station from the action statement of Technical Specification 3.3.3.7.

On December 3, 1982, at 0845 hours0.00978 days <br />0.235 hours <br />0.0014 weeks <br />3.215225e-4 months <br />, an Instrument and Control (I&C) mechanic discovered, during routine operations, that chlorine detector AE5358A was inoperable while AE5358B was still out of service for FCR modifications. At 0910 hours0.0105 days <br />0.253 hours <br />0.0015 weeks <br />3.46255e-4 months <br />, the chlorine detector AE5358A was returned to service after the detector was cleaned, the drip rate adjusted, and Surveillance Test ST 5037.02 was performed to prove operability.

No unit power reductions resulted from the occurrences.

Designation of Apparent Cause of Occurrence: The cause of the December 1, 1982 occurrence was personnel error. Work on chlorine detector AE5358B was first started on November 11, 1982 under an FCR 81-258 work order with AE5358B out of service. This FCR work involved rerouting the piping to the detector. Due to a lack of correctly fitting parts, the work was not immediately completed. On November 22, 1982, the detector was temporarily restored to service since the old sample piping was still intact. Working under the previous Maintenance Work Order (81-258-01), the job proceeded on November 30, 1982 with instructions written on the work order not to make a connection to the chlorine detector. On the following morning, December 1,1982, the Shif t Supervisor discovered the inoperability of the detector, due to disconnected sample piping, and the action statement of Technical Specification 3.3.3.7 was entered.

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TOLEDO EDISON COMPANY DAVIS-BESSE NUCLEAR POWER STATION UNIT ONE SUPPLEMENTAL INFORMATION FOR LER NP-33-82-80 PAGE 2 The December 3, 1982 occurrence, failure of AE5358A, was the result of a component failure - a detector malfunction.

Analysis of Occurrence: There was no danger to the health and safety of the public or station personnel.

In addition to the Control Room Ventila-tion System Chlorine Detectors, local chlorine detectors are placed near the chlorine storage cylinders which would close the intake dampers and isolate the Control Room in the event of a chlorine tank car rupture.

Corrective Action

A memorandum is being sent to the Welding Shop to remind workers to explicitly follow all instructions printed on mainten-ance work orders.

Chlorine detector AE5358A was repaired under the I&C generic maintenance work order 019-82 (Heating, Ventilation and Air Conditioning Control Room), tested for operability by Surveillance Test ST 5037.02, and returned to service at 0910 hours0.0105 days <br />0.253 hours <br />0.0015 weeks <br />3.46255e-4 months <br /> the same day. This removed the unit from the actions required by Technical Specifications 3.0.3 and 3.3.3.7.

Failure Data: There have been no previous occurrences involving the failure to place the Control Room Ventilation System in the recirculation mode per the action statement of Technical Specification 3.3.3.7.

A previous occurrence of a detector failure has been reported in Licensee Event Report NP-33-81-19 (81-018).

LER #82-065 I