ML20012C715

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

ML20012C715
Person / Time
Site:	Davis Besse
Issue date:	03/14/1990
From:	Storz L, Stotz J TOLEDO EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-003, LER-90-3, NP33-90-004, NP33-90-4, NUDOCS 9003230107
Download: ML20012C715 (4)

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L EDO hFossom EDISON PLAZA 300 MADISON AVENUE TOLEDO. OHIO 436524)001 March 14, 1990 Log No.: BB90-00412 NP33-90-004 Docket No. 50-346 License No. NPF-3 United States. Nuclear Regulatory Commission Document Control Desk Vashington, D. C. ~2 0555 Gentlemen:

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LER 90-003 Davis-Besse Nuclear Power Station, Unit No. 1 Date of Occurrence - February 12, 1990 Enclosed please find Licensee Event Report 90-003 which is being written to provide 30' days notificatien of the subject occurrence. This report is being submitted in accordance with 10CFR50.73(a)(2)(1).

Yours truly, r /

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[Y Louis F. Storz Plant Manager Davis-Besse Nuclear Power Station LFS/plf Enclosure cc: Mr. A. Bert Davis Regional Administrator USNRC Region III Hr. Paul Byron DB-1 NRC Sr. Resident Inspector 9003230107 900314 A PDR ADOCK 05000346 f S PDC g)p 7522 ll'/ -

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NAME TELEPHONE NUM0ER AREA CODE Jan C. Stotz, Engineer - Maintenance Planning 4 i l ;9 3,2 1 , ;7;5;4; 4 g

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Au,R ACT iume, M ra ,oeae.s. o , vee,,ewP emee,, ,,0. no unma sae.1 nos on February 12, 1990, at 0123 hours0.00142 days <br />0.0342 hours <br />2.03373e-4 weeks <br />4.68015e-5 months <br />, the Station entered Mode 6, Refueling, without operable audible source range indication. This is a condition prohibited by Technical Specification 3.0.4. It was recognized by the operators about an hour later while reviewing Technical Specification requirements for refueling operations. The action statement of Technical Specification 3.9.2 was immediately invoked. The action statement was not I

violated as there had been no operations involving core alterations or l positive reactivity changes. The cause was personnel error. The licensed operator N/A'd the step on the Mode 6 checklist of DB-PN-06900, Pre-Startup Checklist Procedure, because he thought that Technical Specification 3.9.2 was required only for core alterations and not Mode 6. Subsequent reviews by others failed to correct this mistake. The original out-of-core source range detection channels were operable, however, these channels do not provide an audible source range indication. The functional tests (DB-HI-03455 and 03456) for the new Gamma Metrics detection channel, which supplies the audible indication, were completed at 1430 hours0.0166 days <br />0.397 hours <br />0.00236 weeks <br />5.44115e-4 months <br /> on February 12, 1990. The last open MVO (2-84-0116-25) for the modification that installed the Gamma Metrics was closed on February 17. 1990, and the station exited the action statement of Technical Specification 3.9.2. The individual who statused the item N/A vas I

counseled. Additionally, all licensed individuals vill be required to reviev l

this incident as part of their required reading.

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text w ai . = .ase aac s anso nn Description of Occurrence:

On February 12, 1990, at approximately 0230 hours0.00266 days <br />0.0639 hours <br />3.80291e-4 weeks <br />8.7515e-5 months <br />, while reviewing Technical Specification requirements for refueling operations, the Control Room operators recognized that Hode 6, Refueling, was entered without an operable audible source range indication (IG). Mode 6 vas entered at 0123 hours0.00142 days <br />0.0342 hours <br />2.03373e-4 weeks <br />4.68015e-5 months <br /> on February 12, 1990, when the first Reactor Vessel llead bolt was detensioned.

The audible source range indication is required by Technical Specification 3.9.2 and is applicable in Mode 6. Entry into Mode 6 vithout audible source range indication is a condition prohibited by Technical Specifications. There were no operations involving core alterations or positive reactivity changes.

However, entry into Hode 6 is not allowed (per Technical Specification 3.0.4) without meeting the Limiting Condition for Operation.

The event is reportable under 10CFR50.73(a)(2)(1) as a condition prohibited by Technical Specifications.

Apparent Cause of Occurrence:

The cause was personnel error. Technical Specification 3.9.2 was statused incorrectly as not applicable for entry into Hode 6. The individuals assumed that this was a requirement only for core alterations and failed to properly reconcile this assumption with the Technical Specifications.

Analysis of occurrence:

At the time Mode 6 was declared, Reactor Coolant System pressure was at 0 psig and temperature was at 105'F. There were no core alterations or positive reactivity changes in progress. Source range indication was still available via the original out-of-core source range indication channels, whose surveillance tests were current. The basis for the Technical Specification requirement is to ensure redundant monitoring capability is available to detect changes in the reactivity condition of the core. Not having an operable audibic source range indication under these conditions presented no safety concerns. ,

Corrective Actions:

The individual who statused the item N/A vas counseled on not making assumptions about Surveillance Requirements. On-shift supervising personnel were counseled on this event and on the need to make safe, conservative decisions. They were also counseled on the need to review Technical Specifications on a continuing basis. All licensed individuals vill review this incident as part of their required reading.

An evaluation using the Human Performance Evaluation System (HPES) is ongoing relative to the personnel error, and the results will be addressed via the Station's Potential Condition Adverse To Quality (PCA0) reporting process.

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" - LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Awaovio ows No stto-Oio4 antines w e f actLtty easst (11 pocaat seussissa os PA04 (31 Lam NunsetR tel e =v. w =:n I

Davis-Besse Unit No. 1 0 l5 l0 l 0 j o 131416 9 10 0lOl3 -

01 0 0l 3 0F 0 l 'J fut ame. . mewan. .emannmac a asnawim The functional tects (DB-HI-03455 and 03456) of the two Gamma Metrics detection channels were completed at 1430 hours0.0166 days <br />0.397 hours <br />0.00236 weeks <br />5.44115e-4 months <br /> or. February 12, 1990. When the last open maintenance work order (2-04-0116-25) for these channels was signed off, the station exited the action statement of Technical Specification 3.9.2 at 0600 hours0.00694 days <br />0.167 hours <br />9.920635e-4 weeks <br />2.283e-4 months <br /> on February 17, 1990. No core alterations occurred until after this date.

Failure Data:

A previous event where an entry was made into a mode without all of the surveillance requirements being satisfied was reported in LER 89-001. In that event, a test was statused as N/A because it could not be performed with the 1 plant's existing conditions. The test required full power operation. The I

cause and corrective actions for the event reported in LER 89-001 were not applicable to this event.  ;

REPORT NO.: NP33-90-004 PCAO NO : 90-0088 4

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