Root cause analysis of the June 9, 1985, Davis-Besse event
Equipment failures and human errors have not been designed out of nuclear power plants. Although the tolerance of plants to accept multiple failures and errors without direct harm to the public has been demonstrated repeatedly around the nation, they must find the root causes of failures and errors to assure optimum nuclear safety and protection of their investment and generating facilities. This paper addresses the root causes analysis techniques used following a loss-of-auxiliary-feedwater event on June 9, 1985, at the Davis-Besse Nuclear Power Station. The event started with a capacitor failure causing loss of main feedwater. This was followed by an operator pushing the wrong buttons during the transient. This error was multiplied in impact by steam feedwater rupture control system and auxiliary feedwater pump design deficiencies, equipment failures, and human factors problems. Other equipment failed to perform properly or was damaged as a result of the transient.
- Research Organization:
- Toledo Edison Co., OH
- OSTI ID:
- 6570074
- Report Number(s):
- CONF-860610-
- Journal Information:
- Trans. Am. Nucl. Soc.; (United States), Journal Name: Trans. Am. Nucl. Soc.; (United States) Vol. 52; ISSN TANSA
- Country of Publication:
- United States
- Language:
- English
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Loss of main and auxiliary feedwater event at the Davis-Besse Plant on June 9, 1985
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BOILERS
DAVIS BESSE-1 REACTOR
DAVIS BESSE-2 REACTOR
DESIGN
ENRICHED URANIUM REACTORS
ERRORS
FAILURES
FEEDWATER
HUMAN FACTORS
HYDROGEN COMPOUNDS
LEVEL INDICATORS
MEASURING INSTRUMENTS
MODIFICATIONS
NATIONAL ORGANIZATIONS
OXYGEN COMPOUNDS
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PUMPS
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REACTOR ACCIDENTS
REACTOR COMPONENTS
REACTOR SAFETY
REACTORS
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STEAM GENERATORS
THERMAL REACTORS
TRANSIENTS
US NRC
US ORGANIZATIONS
VAPOR GENERATORS
WATER
WATER COOLED REACTORS
WATER MODERATED REACTORS