United States Nuclear Regulatory Commission - Protecting People and the Environment

Transmittal of NUREG-1154 Regarding the Davis-besse Loss of Main and Auxiliary Feedwater Event (Generic Letter No. 85-13)



                                UNITED STATES
                        NUCLEAR REGULATORY COMMISSION
                           WASHINGTON, D. C. 20555

                               August 5, 1985

TO ALL REACTOR LICENSEES AND APPLICANTS 

Gentlemen: 

SUBJECT:  TRANSMITTAL OF NUREG-1154 REGARDING THE DAVIS-BESSE LOSS OF MAIN 
          AND AUXILIARY FEEDWATER EVENT (Generic Letter No. 85-13) 

On June 9, 1985, Toledo Edison Company's Davis-Besse Nuclear Power Plant 
experienced a loss of all feedwater event while the plant was operating at 
90% power. Shortly after the event, the NRC Executive Director for 
Operations directed that an NRC Team be sent to Davis-Besse, in conformance 
with the staff-proposed Incident Investigation Program, to investigate the 
circumstances of this event. 

The NRC Team has now completed its investigation and has documented the 
factual information and their findings and conclusions associated with the 
event (see c enclosed NUREG-1154, entitled "Loss of Main and Auxiliary 
Feedwater Event at the Davis-Besse Plant on June 9, 1985"). The report 
indicates that a total loss of feedwater is a significant event; and that it
can have severe consequences if actions to ensure prompt and effective 
recovery are not taken. The consequences and significance of the June 9 
event could have been far different had additional equipment failed, had 
additional errors been made, or had recovery otherwise been delayed. Thus, 
there are many possibilities and differing sequences which could have 
affected the safety significance of this transient. 

In terms of their principal conclusion, the team concluded that: the 
underlying cause of the loss of main and auxiliary feedwater event of June 
9, 1985, was the licensee's lack of attention to detail in the care of plant
equipment; the licensee's history of performing troubleshooting, maintenance
and testing of equipment, and of evaluating operating experience related to 
equipment in a superficial manner and, as a result, the root causes of 
problems are not always found and corrected; engineering design and analysis
effort to address equipment problems has frequently either not been utilized
or has not been effective; and that equipment problems were not aggressively
addressed and resolved beyond compliance with NRC regulatory requirements. 

You should review the information for applicability to your facility. In 
addition, you should ensure that the information in NUREG-1154 is made 
available to your plant staff as part of your training program in connection
with the Feedback of Operating Experience to Plant Staff (TMI Action Plan 
Item [.C.5). 


8508020493 

                                    - 2 - 

On August 5, 1985, the Executive Director for Operations (EDO) identified 
and assigned responsibility for generic and plant-specific actions resulting
from the investigation of the Davis-Besse event. Some of the generic actions
may be applicable to your facility. A copy of the EDO memorandum is included
for your information. 

This generic letter is provided for information only, and does not involve 
any reporting requirements. Therefore, no clearance from the Office of 
Management and Budget is required. The enclosed report is currently under 
NRC review.  Any generic requirements stemming from the report will be 
transmitted at a later date following completion of the appropriate 
procedural steps. 


                              Hugh L. Thompson, Jr., Director 
                              Division of Licensing 

Enclosures: 
1.   NUREG-1154 
2.   EDO Memorandum of August 5, 1985 
3.   List of Generic Letters
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