05000304/LER-1988-001, :on 880108,nuclear Station Operator Failed to Log Delta I W/Nuclear Instrumentation Channel in Test.Caused by Failure to Respond to Control Room Indication.Operator Training Conducted
| ML20055G751 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 07/20/1990 |
| From: | Joyce T, Stevens E COMMONWEALTH EDISON CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LER-88-001, LER-88-1, NUDOCS 9007240135 | |
| Download: ML20055G751 (6) | |
| Event date: | |
|---|---|
| Report date: | |
| Reporting criterion: | 10 CFR 50.73(a)(2)(iv), System Actuation 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2) 10 CFR 50.73(a)(2)(viii)(B) 10 CFR 50.73(a)(2)(iii) 10 CFR 50.73(a)(2)(x) |
| 3041988001R00 - NRC Website | |
text
-
,s-Commonwestth Edison i
c u.iloh.
.a igen 00e.
elephone 708 / 746 2004 l
l July 20, 1990 U. S, Nuclear Regulatory Commission 3
Document Control Clerk Washington, D.C.'
20555
Dear Sir:
The Enclosed Licensee Event Report number 88-01-02, Docket No.
50-304/DPR-48 from Zion Generating Station was previously transmitted to you l
as report number 88-01-01 on May 7, 1990.
The correct number is 88-01-02.
There are no other changes.
i Very truly yours, i'JtVJ T. P. Joyce i
Station Manager Zion Generating Station TPJ/tpm-
Enclosure:
Licensee Event Report cc: NRC Region III ^dministrator NRC Resident Inspector INPO Record Center CECO Distribution List I
i i
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1011D r-n 2577o-9007240135 900720 gDR,ADOCK0500g'g4 g[g-g
+
LICEN$EE EVENT REPORT (LER)
FaclittyName(1)
Docket Number (2)
EAge (3)
Zion. Unit 2 01 51 01 01 01 31 Oj 4 1!of!OI5 Title (4)
Nutlitt $L1119tLQattjigLIAllure to lor _dtlia I with Nu.tltar Instrumentation Channel in Test._
luni Date f 5)
LER Nuthtcl6)
Report Date (7)
Other Facilities involved (B) N/A Month Day Year Year
/j//
// Sequential
/// Revision Month Day Year
__ Facility N_ames Docket Nud er(s) ff fff
/
Nuttt __llL luter N/A 015101010] I l
~
~
.01 1-01 8 81 8 81 8 01011 01 2 017 2Lo 910 0151 DI n.LDI I I
^"
OPERATING ILtittkant._gr more of_1he following}_ (11)
HDDE (9) 1 20.402(b) 20.40$(c) 50.73(a)(2)(iv) 73.7)(b)
POWER 20.405(a)(1)(1) 50.36(c)(1)
__. 50.73(a)(2)(v)
,_ 73.71(c)
LEVEL 20.40$(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vil)
Other ($pecify
_1.19) 0
.9 9
20.405(a)(1)(lit).jL $0.73(a)(2)(1) 50.73(a)(2)(vitt)(A) in Abstract below
//////////////////////////
20.405(a)(1)(tv) 50.73(a)(2)(ti) 50.73(a)(2)(viii)(B) and in Text)
//////////////////////////
20.405(s)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)
Ll((!i$(E_CONTAET FOR THIS LER (12)
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COMPLETE Qtill.!NE FOR EADLLOMPONENT FAILURE DESCRISED IN THIS REPORT (13)
CAUSE
$YSTEM COMPONENT MANUFAC-REPORTABLE
CAUSE
$YSTEM COMPONENT MANUFAC-REPORTABLE TURER TO NPRDS-TURER
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Expected tionth Lois LYstE Submission
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ABSTRACT (Limit to 1400 spaces, i.e. approximately fifteen single-space typewritten lines) (16)
The delta-I logging program on the Unit 2 process computer was automatically deactivated at 2014 January 8, 1988 during channel functional tests on power range channel 41, and delta-I was not manually logged untti 2300. Technical Specification 4.2.2.A.5 requires that delta-1 be manually logged until the delta-1 program is restored. The event ended at 2300 when the nent shift Nuclear $tation Operator (NS0) acknowledged the alarm indications and began to manually log delta-1. The delta-1 program was restored at 2330 on January 8,1988, terminating the need for the manual log. The missed survelliance of logging delta-1 is a result of personnel error resulting f rom the NS0's misconception that the channel test pre-empted the requirement to manually log delta-1. Unit 2 was at 99.4% power and the delta-1 values stayed within the operating band throughout the incident.
l l
1 LILEN1([_iyLMI. REPORT fL(R) TEKT CONTINUAI10N FACILITY NAME (1)
DOCKET NUMBER (2)
LER NUPSER (6) page 13)
{
Year
///
Sequentist
///
Revision fff fff W - Kumker--. UL. HuektL l
Zion. Unit 2 0 1 5 1 0 1 0 1 0 1 31 01 4 8l8 01011 01 2 01 2
.0F DL5 TEXT Energy Industry identification System (E!!$) codes are identified in the text as (xx) 1 l
A.
El4MI_CQHD1110R$310R 10 EVLHI:
a H0DE 1
.fortLQMn119n. RX power Ed, RC$ (AB) Temperature / pressure
$$8 'F/ 22&funig j
B.
DL$CRIE110N OF EVEN1:
On January 8, 1908, Instrument Maintenance performed a Nuclear Instrumentation $ystem (NI$) [!G) power range functional test on channel 41 of Unit 2 per Instrument Haintenance procedure 2N-41 E.
At 2014 the NIS computer points for channel 41 were placed in scan mode for an on-line section of the test which caused the delta-1 program to deactivate the delta-1 calculation as it sensed a deviation between the 4 delta-1 channels. This is an expected consequence of the procedure and is not considered an anomalous event. Accordingly the control room alarm typer printed " DELTA FLUX - QUE$i10NABLE CALCULA110N - Hl$f0RY TABtt$ WILL NOT BE UPDATED BEGIN HANUAL LOGGING OF DELTA 1 per pT-14A".
The Nuclear $tation Operator (N$0) did not acknowledge this message on the alarm typer. With the process computer delta-1 program not actively logging delta-!, Technical $pecification 4.2.2.A.$ requires hourly manual logging of delta-1 for the first 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> and then every half hour thereafter. The control room display monitoring system provided an alternate inalcation that the delta-1 program was offline as it displayed six cyan X's where the usual delta-! value is given. The N$0 noted this condition and was aware of the delta-1 logging Technical $pecification requirements.
The delta-1 program has provisions for using three channels when one is in test but part of the procedure requires that the computer points for the channel be returned to scan to verify an axial offset and other computer values against corresponding detector current values. in the functional procedure 2N-41 [ the i
instrumentation Hechanic (IM) manually sets the power range channel currents to predatermined values which correspond to an axial offset of zero for five simulated power levels of 0, 30, 60, 90, and 120 percent.
The computer processes signals proportional to these currents to yield axial offset values which provide verification of the channel and computer functionability. The computer utiltres the currents as if they were representing actual core conditions. When any of the four channels (in this case the channel in test) varies by more than 2 percent from the average of the other 3 channels, the delta-! program internally disables the delta-! calculation and the logging of the delta-1 values.
l The N50 is responsible for reactivating the delta-! program af ter the condition causing the " questionable calculation" is rectified by requesting the Shift Engineer to reset the program. It is the NSO's option to either log delta-1 manually or see that the delta-1 program is restored so that the Technical
$pecification requirement is met. The alarm typer called for NSO action on the matter once per minute throughout the event. The event ended at 2300 when the oncoming NSO acknowledged that delta-1 was not being logged either by the computer or manually and started logging delta-1 per pi-14A. The $hift Engineer reset the delta-1 program at 2330 on January 8,1988 to restore computer logging of delta-1.
During the investigation of this event, it was noticed that the Quadrant power Tilt Ratio (QpTR) had not been determined hourly while the encore channel was inoperable during IH calibration, as required by Technical $pecification 4.2.2.C.2.
QpTR is defined as the ratio of the maximum upper excore detector calibrated output to the average of the upper excore detector calibrated outpets, or the ratio of the mi.imum lower excore detector calibrated output to the average of lower excore detector calibrated outputs, whichever is greater. QpTR is used to determine if radial flux distribution enomalies exist. and 1.02 is the maximum allowable value. This was an additional missed surveillance, i
L1LLWiLLEVIMLREP0ai itral TEKLCOMIINVA110N FACILITY NAME (1)
DOCKET NUPSER (2).
_ LtR NUpeLIL16)
....... pnge f 3) j//
Sequential //j/
Revision
/
Year ff f/j//
Numbet UI -_Maher
~ Zioh_Vall.2
_01.5_.LoJ 0J_ol31014 8 I e-oIo11 oi2 0L11 _0L5 TEXT Energy Industry Identification System (E!!$) codes are identified in the text as (xx)
C.
LAVALQLiv1MI:
1he primary cause of the event is the Itcensed N$0's f ailure to respond to a control room indication. The N50 f ailed.to acknowledge the questionable computer calculation of the delta-1 condition and either begin manual logging of delta-1 or have the delta-! program restored when feasible. He took neither action for the remainder of his shift, approximately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> and 45 minutes. The reason he took.io action was his belief that while the IH was performing the channel 41 functional test, delta 1 manual surveillance was I
not required.
Usually the IM's finish simulating the five power levels and complete the procedure within an hour. The Shif t Engineer then resets the program well before the NSO would be required to log delta-! for the first hour. The N$0 grew accustomed to this pattern of waiting for the IH to finish before resetting the delta-1 program. This particular test took longer than usual $1nce one IH was performing it rather than 3
two. The H50 aivumed that the charnel calibration had to be completed prior to resetting the delta 1 program, and that while the IM's were performing the NIS functional procedure, the Tech $pec did not apply. The NSO also had limited knowledge of how the IH test procedure was affecting the unit's delta-!
program.
The cause of the missed Qp1R surveillance was that Operating personnel assumed that the surveillance requirements fir an inoperable encore channel did not apply during IH calibration.
D.
MIRY 11$ Of EVif1:
Unit Two remained at 99% power throughout the event, process computer data for delta I was retrieved from this time period and is shown on figure 1.
It shows that delta-1 increased slightly from approximately -0.6% to -0.4% from the beginning to the end of the event. The allowable delta-! band for Unit 2 at 99% power is between -7.3% and 5.7%.
During the 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> and 45 minutes of the event, the automatic QpTR calculation was also disabled by the t
inoperable excore channel. Manual logging, which was then required hourly, was not performed. The following analysis demonstrates the safety significance of the Unit 2 missed QPTR calculation.
The Westinghouse Data f rom this time interval (Attachment 1) yields the calorimetric power level, each power range channel axial of f set, dates, times and burnup. This, with the installed 100% excore currents, allows for the calculation of QpTRs during the excore functional checkout. The steps (shown on Attachments 2, 3, 4) were:
1.
Back-calculate channel 42, 43, 44 currents from known axial offsets (which were calculated from those currents).
2.
Determine four channel current sum for the " micro-amps per 100% power" ratio (from data before and after the event).
3.
The currents for Channels 42, 43, and 44 are then subtracted from the total current at the specific E
power level. This yleids the current for Channel 41.
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LICER$((_ EVENT RLf'QRT (LER) TEXT CDMIINUATION FACIt11Y NAME (1)
DOCKET NUMBER (2)
_ LER NU@ER (6) page (3)
Year
///
Sequential ff//j Revision
/
fff Ul h mktL-- UL HVMkLE-
_... Zion d nit 2 0 l 5 1 0 1 0 l QJ 1L91 4 - 8I8I-0 Lo I 1 DJ 2 ol 4 Or 01 s 1 EXT Energy Industry Identification System (Ells) todes are identified in the text as (xx)
D.4 With all four Channel currents known, the QPIR calculation is done:
a.
Each channel current is divided by its respective 100% current yielding a power f ractional representation, b.
The power fractions are then averapsd.
c.
The individual channel power fractions are divided by the averaged power fraction. This yields a QPTR value for each channel. These values comprise the QPIR surveillance.
The greatest tilt did not exceed 1% during the course of the event. The Tech Spec action limit is 2%.
An error analysis was performed on the most limiting tilt, to demonstrate that no significant error was introduced in back-calculating currents from a rounded axial offset value of fewer significant figures.
The axial offset values were altered with an additional significant figure. They were altered in such a way as to yield the worst possible tilt. However, the result shows the worst tilt still less than 2% (See ). This leaves all other tilts well within limits for the duration of the event.
In conclusion, no margin ensuring public safety was sacrificed or diminished throughout the course of this event.
.E.
(DRRECTIVE ACT108):
As a short term corrective action, the involved NS0 reviewed the program description of the delta I program to better understand what the program does and how it is affected by IH testing (304-180-88-00100.1). Three long term actions were taken to prevent recurrence. Technical Staf f investigated changes to the IH calibration procedure to have the IH toggle channel currents into scan mode while the channel is still in test. This will enable the IH to complete the procedure without interrupting automatic logging of delta 1.
The IH calibration procedure was revised to add an NSO signoff, cautioning him on the potential for additional Technical Specification surveillance requirements associated with the NIS channel calibraHon.
Operator training was conducted, discussing the effects of IH calibrations and tests on the Unit, and emphasizing those IH procedures which have the potential for requiring additional NSO actions.
- The corrective actions for the missed QPTR surveillance are that the Technical Specification and its appitcability during IH testing were covered in the Operator training discussed above. As an immediate corrective action, Standing Order 88-02 was issued on January 28, 1988, stating the surveillance requirements of Technical Specification 4.2.2.C.2 for an inoperable excore channel, and explicitly stating that these requirements apply when a power range excore channel is inoperable due to IM calibration or maintenance which affects operability. The requirements of Standing Order 88-02 were subsequently incorporated into station procedures and the Standing Order was cancelled on 11/10/88.
k LICIM$LLIyLMT REPORT (LER) TEXT CQKIINUA110N F
FACIllTV NAME (1)-
DOCKET N'JHBER (2)
_1LLNutBER (6) page 01 Year
///
Sequential /jj//
Revision c
/j/jjL Number
/j/1 _Humban, Zion. Unit ~2
_L} $ l o_lJLI s_.L1Lol 4 8 I e oIoIi 01 2 o f 53L A_5 1 EXT Energy Industry Identification System (E!!$) codes are identified in the text as (xx)
F.
ERLY10U13CfURBCNCL$
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This same Tech $pec vlotation occurred in LIR 84-027. At that time, the corrective actions consisted of training for the NS0's, clearer alarms on the control room monitor, and automatic messages on the control room alarm typer..
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SUMMED upper detector lower detector lower A CURRENT
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Currents slope currents slope ratio TOTAL'o
\\ 74u+ A1/
(Au+Alf M48.1l0.*15 1.125 160.515
- - 1.125 1.012472 323.028 O.503098 O.496901 G41 147.789 O.947 142.652
- - 0.947 1.05601O 290.441-O.508843 O.491156 LM#3 112.105 1.255 178.151
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% POW metric CH41 CH42 CH43 CH44 100% POW power
.0:';93600 3229.3
- - 0.42
- - 0.81
- - 0.63
- - 0.63 1000.324 O.994246 5231.3
- - 0.38
- - 0.76
- - 0.63
- - 0.71 1329.409
- 0. '? B8215 3211.7
- - 0.58
- - 0.65
- - 0.59
- - 0.59 1337.519 0.'iB3753 3197.2
- - 0.38
- - 0.67
- - 0.63
- - 0.5 1343.586 02 '?B5076 3201.5
- - 0.38
- - 0.72
- - 0.63
- - 0.71 1041.780 02 ClB8092 3211.3 N
- - 0.63
- - 0.42
- - 0.5 CV;85415 OOO2.6 0
- - 0.54
- - 0.5
- - 0.46 h
O0789969 0217.4 7
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- - 0.29
- - 0.34
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O.085476 3202.8
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- - 0.45
- - 0.17
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- - 0.4
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- - 0.31
- - 0.17
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- - 0.27
- - 0.13
- - 0.21
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- - 0.17
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- - 0.56
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- - 0.39307
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dwrenh kn/op<d in 5fef I e.
l CH41 CH42 ACTUAL ACTUAL ACTUAL FULL SUM UPPER LOWER BUM 102.9904 160.9825 323.975 148.1793 142.2752 290.4545 162.9451 160,9376 323.883 148.155'a 142. 2985 290. 4537 162.9451 160.9378 323.883 148.0925 142.3589 290.4515
=
162.9451 160.9378 323.883 148.1118 142.3403 290.4522 162.9451 160.9378 323.883
- d" 148,1359 142.3171 290.4530 322.5948d S
148.0925 142.3589 290.4515 319.0179 148.0492 142.4008 290.4500 325.1068 148.0492 142.4008 290.4500 319.3037 148.0492 142.4008 290.4500 326.5903 148.0058 142.4426 290.4485 328,1529 147.9798 142.4678 290.4476 327.2920 147.9383 142.5078 290.4461 318.6994 147.9191 142.5264 290.4455 325.5674 147.8757 142.5682 290.4440 f
323.6353 147.8082 142.6333 290.4416 h
321.2457 147.9624 142.4845 290.4470 323.8344 147.9817 142.4659 290.4476' 322.9680 148.0058 142.4426 290.4485 162.9451 160.9378 323.883 148.0684 142.3822 290.4507 1G2.5602 160.5577 323.118 147.8757 142.5682 290.4440 102.9451 160.9378 323.883 147.9624 142.4845 290.4470 162.4697 160.4682 322.938 147.9191 142.5264 290.4455 162.6621 160.6583 323.3205 147.9624 142.4845 290.4470 CH43 CH44 ACTUAL ACTUAL ACTUAL ACTUAL
- - UPPER LOWER SUM UPPER LOWER SUM 182.5046 177.7600 360.2646 174.4180 172.7409 347.1590 lb2.5046 177.7600 360.2646 174.4667 172.6905 347.1592 182.4792 177.7848 360.2641 174.3937 172.7651 347.1588 182.5046 177.7600 360.2646 174.3390 172.8195 347.1585 182.5046 177.7600 360.2646 174.4667 172.6925 347,1592 182.3714 177.8903 360.2617 174.3390 172.8195 347.1585 182.4221 177.8406 360.2628 174.0147 172.8437 347.1584 182.2889 177.9710 360.2599 174.2417 172.9163 347.1580 182.2889 177.9710 360.2599 174.1870 172.9707 347.1577 182.2128 178.0454 360.2583 174.2417 172.9163 347.1580 182.2610 177.9983 360.2593 174.2089 172.9489 347.1579 182.2128 178.0454 360.2583 174.1870 172.9707 347.1577-182.1874 178.0703 360.2577 174.1626 172.9949 347.1576 182.2128 178.0454 360.2583 174.1383 173.0191 347.1575 e
{
182.2889 177.9710 360.2599 174.1626 172.9949 347.1576 102.2382 A78.0206 360.2588 174.2417 172.9163 347.1580 182.2889 177.9710 360.2599 174.2660 172.8921 347.1582 182.3968 177.8655 360.2623 174.2113 172.9465 347.1579 182.3460 177.9161 360.2612 174.2417 172.9163 347.1580 182.2889 177.9710 360.2599 174.1383 175.0191 347.1575 192.1874 178.0703 360.2577 174.2113 172.9465 347.1579 L
- - 182.1974 178.0703 360.2577 174.1383 173.0191 347.1575 182.2382 178.0206 360.2588 174.1626 172.9949 347.1576 w_
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- - 0.17
- - 0.17 s
O.588861 0013,8 A
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- - 0.29
- - 0,21 O.987076' 7008 B
- - 0.76
- - 0.21
- - 0.34 O.589015 0214.3 L
- - 0.4
- - 0.29
- - 0.~8 O.988369 7010.O E
- - 0.45
- - 0.46
- - 0.2' O.489508 5016
- - 0.38
- - 0.58
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- - 0.34 1576.559 0.*B9061 0015.1
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- - 0.06
- - 0,13
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- - 0.36
- - 0.21
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- 1. VM Ot 6
- o9051 1.UU1953 O. W9505 O.999260 0.**o*40 1.000006-O.090974 c.;+*918 l
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