05000346/LER-1989-001, :on 890105,determined That RCS Flow Surveillance Test Not Performed When Entering Mode 1 After Refueling.Caused by Personnel Error.Event Discussed W/ Personnel Involved in Signing Checklist

:on 890105,determined That RCS Flow Surveillance Test Not Performed When Entering Mode 1 After Refueling.Caused by Personnel Error.Event Discussed W/ Personnel Involved in Signing Checklist

ML20077K230
Person / Time
Site:	Davis Besse
Issue date:	07/30/1991
From:	Storz L, Stotz J TOLEDO EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-001, LER-89-1, NP-33-89-001, NP-33-89-1, NUDOCS 9108070124
Download: ML20077K230 (4)

LER-1989-001, on 890105,determined That RCS Flow Surveillance Test Not Performed When Entering Mode 1 After Refueling.Caused by Personnel Error.Event Discussed W/ Personnel Involved in Signing Checklist

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(1)
3461989001R00 - NRC Website

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KIO MAD 60N AVI NOC 10tI()O 0W013M2 (101 Log Not All-91 -0016 NP-33-89-001, Revision 1 July 30, 1991 Docket No. 50-346 License No. NPF-3 U. S. Nuclear Regulatory Commission Document Control Desk Vashington, D. C.

20555 Gentlemen:

LER No.89-001, Revision 1 Davis-Besse Nuclear Power Station Unit No. 1 Date of Occurrence - January 5, l_989 Enclosed is Licensee Event Report 89-001, Revision 1 which is being submitted to update the status of the corrective ections.

Additionally, upon further reviev, Toledo Edison determined that the proposed corrective action to request a Technical Specification (T.S.) change to allow deferring the T.S.

surveillance testing for the reactor coolant system flow rate until entry into Mode 1, is not required.

Accordingly, Toledo Edison has deleted this request as a corrective action and vill continue to perform the present T.S. suiveillance requirement for the reactor coolant system flow rate.

Yours truly, L

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Louis F. Storr Plant Manager Davis-Besse Nuclear Power Station LFS/ach cci Mr. A. Bert Davis Regional Administrator USNRC Region III i

Mr. Paul Byron y

l DB-1 NRC Sr. Resident Inspector j

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n ei ABSTRACT on January 5, 1989, the reactor was operating in Mode 1 at 100 percent reactor power.

It was determined that a Reactor Coolant System Flov surveillance test required by Technical Specification 4.2.5.2 had not been performed. This required the plant to enter Technical Specification 3.0.-3 vhich requires a plant

- shutdown.

Permission was requested and received from the Office of Nuclear Reactor Regulation and the Division of Reactor Projects, Region III to continue operation until the test could be completed. The test was satisfactorily completed on January 5, 1989. This occurrence was discussed with appropriate personnel involved in signing off the Mode Checklist by February 28, 1989.

The purpose of the Critical Surveillance Test Report and its importance was emphasized'vith the systems engineers involved in the Surveillance Testing

. Program. The Surveillance and-Periodic Test Program Procedure, DB-DP-00013, was revised to formalize the transfer of tests by March 1, 1989.

The Plant Manager reet with the responsible Department lieads by March 6, 1989, to re-emphasize the importance of following the Surveillance Test Program and rescheduling tests when circumstances dictate.

This condition is being reported in accordance with 10 CFR 50.73(a)(2)(1)(B).

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_ _ _ =ac % n.., u n Description of Occurrence:

On November 3 1988, with the reactor in Mode 5, Surveillance Test DB-SP-03358 for surveillance requirement 4.2.5.2, Reactor Coolant System Flow Heasurement-exceeded its Technical Specification late date..This Technical Specification requirement is applicable in Mode 1.

The critical surveillance test report vhich is sent to the cognizant managers for notification and scheduling et surveillance tests identified test D5-SP-03358 as past its Technical

- Specification-Late Date. This report f,e Mode 1-testing was issued on

- approximately November 28, 1988. The Mode Checklist, which is used to verify that surveillance _--test requirements are current prior to changing modes, was completed for Mode.1-on December 15, 1988. - The step of the Mode Checklist for Surveillance Test DB-SP-03358, which required plant conditions that could only be achieved while in Mode 1, was inappropriately signed off.

On December 17, 1988, the reactor began power ascension and entered Mode 1.

On January 5, 1989, while the reactor was operating in Mode 1 at 100 percent reactor power, it was determined that the surveillance test requirements of Technical Specification 4.2.5.2 had not yet been performed. 'This required the plant to enter Technical Specification 3.0.3 and initiate a plant shutdown.

Permission was requested and received from the office of Nuclear Reactor Regulation and the Division of

- Reactor-Projects, Region III to continue ope. ration until the test could be completed. The test was satisfactorily completed on January 5, 1989. This occurrence is being reported in accordance with 10 CFR 50.73(a)(2)(1)(B).

Apparent Cause of Occurrence:

This occurrence vas caused by personnel errors.

Surveillance Test DB-SP-03358 was last performed on March 17, 1987. 'The personnel error can be summarized as follows:

1.

Miscommunication between Performance Engineering, and Systems Engineering regarding responsibility for performing the test and rev.ieving test

- results.

These responsibilities had been transferred from Performance Engineering to Systems Engineering earlier in 1988.

- 2.

Inadequate understanding by Systems Engineerinr; of the application of the Technical Specification late date allowances per paragraph 4.0.2.-

3.

Inattention to the Critical Surveillance Test Report for this item by

• Systems Engineering. This report had been used by Systems Engineering previously for selected Surveillance Test performance responsibilities.

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Incorrect interpretations of Technical Specification surveillance requirements by Operations. The operators _vho signed off the Mode

- Checklist knev_that the surveillance test vas past due, llovever, the prerequisites:for the test required the plant to be operating greater than 70 percent reactor pover.

After reviewing the test, the operators incorrectly assumed that entry into Mode 1 vas permitted la order to implement the test and signed off the applicable step in the Mode Checklist and noted this situation on the checklist._

Analysis of Occurrence:

Periodic Test DB-SP-04360, which measures Reactor Coolant Systems (RCS) flov in Mode 3, was. satisfactorily performed on December 2, 1988 and indicated nominal RCS-flov. When surveillance test DB-SP-03358 vas performed no unsatisfactory readings vere noted. Therefore, the entry into Mode 1 vithout performing the surveillance test had no safety consequences.

Ccrrective Actions:

This occurrence was discussed.vith appropriate personnel involved in signing off the Mode Checklist-by February 28, 1989. The purpose of the Critical Surveillance Test Report and its importance vas emphasized vith the systems

- engineers involved in the Surveillance Testing Program.

The process.of transferring surveillance tests from one organization to another was. formalized in.the Surveillance and Periodic Test Program Procedure DB-DP-00013.by March.1, 1989. The Plant Manager met with the responsible Department lleads by March 6, 1989, to re-emphasize the importance of following the Surveillance Test Program and rescheduling tests when circumstances dictate.

Failure Data:

This is the second report of changing modes with a surveillance test past it Technical' Specification Late Date.

LER 81-079 describes-a sir:ilar occurrence-

~however, the root cause vas not related.

REPORT NO.1 NP-33-89-002 PCAO NO.:

89-0011

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