IR 05000397/1993010
| ML17290A231 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 04/01/1993 |
| From: | Johnson P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17290A230 | List: |
| References | |
| 50-397-93-10-MM, NUDOCS 9304200207 | |
| Download: ML17290A231 (79) | |
Text
U. S.
NUCLEAR REGULATORY COMMISSION'EGION V
Report No.:
License No.:
Licensee:
Facility Name:
Meeting at:
Date of Meeting:
Prepared by:
Approved by:
50-397/93-10 NPF-21 Washington Public Power Supply System P.
O.
Box 968 Richland, Wa 99352 Washington Nuclear Project No.
(WNP-2)
Supply System Headquarters Richland, Washington March 4, 1993 D. L. Proulx, Resident Inspector, WNP-2-(~
P.
H. 'son, C ief React Projects Section
I ~
Date Signe Meetin Summar
Mana ement Meetin on Harch
1993 Re ort No. 50-397 93-10 An open Hanagement Meeting was held to discuss current operations issues, including performance during the period encompassing January 21 through February 16, 1993 at WNP-2.
Discussions also covered licensee lessons learned and corrective actions for the events of this period.,
930eaOoaaV moOOa
.PDR ADOCK 0500039'1
DETAILS 1.
Heetin Partici ants Nuclear Re ulator Commission K.
P.
J.
D.
R.
D.
E.
H.
W.
F.
C.
L.
Perkins, Director, Division of Reactor Safety and Projects Johnson, Chief, Reactor ProjectsSection I Clifford, Project Manager, Nuclear Reactor Regulation Kirsch, Techni cal Assi stant, Regi on V
Barr, $enior Resident Inspector, WNP-2 Proulx, Resident Inspector, WNP-2 Mashin ton Public Power Su
S stem A. L.
J.
V.
J.
C.
R. L.
J.
M.
G.
C.
G. 0.
R. L.
L. T.
D. J.
J.
E.
J.
W.
W. D.
C. H.
A. G.
R. E.
D. L.
T. C.
R. J.
N. D.
P. J.
L. D.
D. H.
H. S.
R.
H.
T. L.
A. A.
G. J.
G.
B.
P.
D.
G. A.
H. V.
J. T.
D.
G.
H. L.
D. L.
J.
C.
W. A.
Oxsen, Acting Managing Director Parri sh, Assistant Managing Director for Gearhart, Director, guality Assurance Koenigs, Acting Director, Engineering Baker, Plant Manager Sorensen, Manager, Regulatory Programs Smith, Operations Division Manager Webring, Technical Services Manager Harrold, Maintenance Division Hanager Pi sarcik, Radiation Protection Manager Wyrick," Outage Manager Dabney, Work Control Manager Shaeffer, Operations Manager Halbfoster, Chemistry Hanager Hosier, Licensing Manager Mathews, Design Engineering Manager Larkin, Engineering Services Manager Messersmith, Maintenance Support Manager Barbee, System Engineering Manager'immerman, Plant Technical Supervisor Inserra, Plant Technical Supervisor Sharpe, Plant Support Engineering Supervi Thomsen, Fuels Engineering Supervisor Collins, Maintenance Services Supervisor Torres, Reactor Engineering Supervisor Meade, Plant Technical Supervisor Langdon, Shift Manager Kozlik, Shift Manager Hendrick, Shift Support Supervisor McBurney, guality Assurance Engineer Block, guali ty Assurance Engineer Rice, Plant Support Engineer Person, Procurement Engineer Weber, Design/Drafting Nielson, Chemical Engineer Moon, Nuclear Safety Engineer Howery, Design Engineer Kiel, Licensing Engineer Operations sor
B. L. McInturff, Electrical Maintenance K. C. Huber, Equipment Operator J.
L. Zei lstra, Health Physics Technician Bonneville Power Administration J.
F. Lewis, Program Director D. L. Williams, Nuclear Engineer Washin ton Ener Facilities Site Evaluation Council EFSEC J. J. Zeller 2.
Mana ement Meetin of March
1993 On March 4, 1993, an open meeting was held at the Supply System Head-quarters Office in Richland, Washington, with the individuals identified in section 1.
The purpose of the meeting was to discuss current operations issues, including performance during the period from January 21 through February 16, 1993.
The meeting also covered licensee management expectations, lessons learned, and corrective actions for the problems encountered during the events of this period.
The meeting convened at 8:30 a.m.
3. ~ik Nr. Perkins stated that the events and performance issues of the time period beginning'ith January 21 were of concern, and led one to ques-tion the effectiveness of the Supply System's improvement programs.
He said that some common themes appeared to arise during this time period, including repeat equipment failures, human errors, poor integration of industry information, and ineffective management oversight.
Mr. Perkins then expressed his desire for the meeting to center upon lessons learned and corrective actions rather than the technical details of the events.
Mr. Oxsen noted that the Supply System is a company in transition with many new senior managers being hired or recently in place.
He further stated that he agreed that there were significant performance issues and numerous opportunities in which the Supply System could have performed better.
He added that to the credit of his people, the Supply System had initiated a "management time out" when it was evident that performance problems appeared to be compounding.
4.
Presentations b
the Su
S stem Supply System representatives then provided presentations on the topics outlined in the enclosed agenda.
Each of the presentations used slides which the Supply System had prepared.
A copy of the slides used during the licensee's presentations is enclosed as an attachment to this report.
a.
Mr. Smith summarized the Operations Department's performance; with emphasis on problems associated with the containment exhaust purge (CEP) valves, the recirculation pump trip and manual reactor scram, and the degradation of the high pressure care spray (HPCS) battery.
Mr. Perkins emphasized that the Operations Department should be
running the plant, and that the other organizations should be support organizations.
Nr. Johnson stated that the issues associated with the CEP valves, the recirculation pump trip, and the degradation of the HPCS battery appeared to indicate a reluctance among operations personnel to call the technical staff for help.
Both Nr. Kirsch and Hr. Perkins noted that management barriers also failed to identify the problems associated with the CEP valves and the HPCS battery.
Nr. Kirsch expressed his concern that several of the events during the period following January 21 involved personnel apparently proceeding in the face of uncertainty.
The licensee acknowledged the NRC's comments.
b.
Nr. Mebring summarized the Technical Services staff's performance, with emphasis on issues associated with the low pressure turbine (LPT) balancing, the CEP valves, loss of the "8" reactor feedwater pump (RFP),
and failure of the recirculation flow control (RFC)
valve to run back.
Nr. Baker commented that in some instances, management was too close to the technical issues and was not providing critical oversight.
Nr. Proulx commented that it appeared that Root Cause Assessment and guality Assurance (gA) personnel were not adequately involved in the above issues from a trending and problem resolution perspective.
Hr. Perkins and Nr. Johnson stated that System Engineers (SEs) apparently need to get more involved with work and other issues associated with their systems.
Mr. Kirsch added that the Supply System has appeared to be living, with a number of known problems, and has at times encountered recurring technical problems or plant events.
Hr. Kirsch noted that these two facts can undermine improvement initiatives that the licensee plans to under take.
The licensee acknowledged the NRC's comments.
C ~
Nr. Koenigs and Mr. Hathews discussed issues associated with the Engineering Directorate, as shown on the attached slides.
Nr. Barr noted that the repeat failure of the diesel generator may have been precluded if an effective change management analysis program had been in place.
Hr. Perkins repeated his concern that corporate and site engineering do not properly recognize their responsibility for the plant and its continuing safe operation.
d.
Mr. Harrold discussed performance issues associated with the Mainte-nance Department.
Mr. Kirsch noted that in his plant tours, a lack of respect for plant equipment was evident on the part of some workers.
This included observations of workers stepping on instrument lines and piping insulation.
He stated that maintenance personnel appear to require closer supervision and training.
Mr. Perkins stated that maintenance personnel in good performing plants have more questioning attitudes and less willingness to live with problems.
They work in support of Operations personnel.
e.
Mr. Gearhart discussed the gA organization's role in identifying and correcting the recent performance issues.
Hr. Perkins commented that gA appeared to be competent in finding problems, but generally was not thorough in followup actions.
He questioned why gA improve-ments were being delayed until after the spring refueling outage, in
light of the number of problems the Supply System was experiencing.
Hr. Gearhart said that was because of the approvals which were necessary.
f.
Hr. Baker, Hr. Dabney, and Hr. Wyrick discussed problems and correc-tive actions associated with forced outage management.
Mr. Perkins asked the licensee if the lessons learned from the recent forced outage have been incorporated into the ongoing fuel pool cooling (FPC)
system outage.
The licensee acknowledged that no single person was in charge of the FPC outage, and that the Supply System was still in the process of fully implementing the corrective action from the recent events.
Hr. Perkins pointed out that this created a
difficult situation for the on-shift crews.
g.
Mr. Parrish described the process, results, and recommendations from the
"Management Time Out," as outlined in the attached slides.
h.
Mr. Sharpe then discussed issues associated with reactor pressure vessel level anomalies.
Hr. Perkins questioned whether the licensee had considered all possible leakage paths (e.g.,
across equalization valves).
Hr. Johnson stated that the engineering staff apparently did not adequately communicate its initial findings to the plant staff or to the NRC.
He added that the month-long time period for the operability judgement appeared to be excessive.
5.
Closin Remarks In conclusion, Hr. Johnson stated that WNP-2 has a wealth of talented people, but should require personnel to have a lower threshold for problems, strive for better ownership and pride in the plant, and focus management and gA on fundamental performance issues.
Hr. Clifford stated that he appreciated the exchange of information, and the Supply System's candor.
However, he expressed his perception that the Supply System appeared to be reluctant to involve gA groups early in problem resolu-tion, and that operators needed to develop a more questioning attitude.
Hr. Barr added that it appeared that the Supply System was aware of their problems, but that detailed programs for long term improvement were not apparent.
Hr. Perkins stated that the Supply System appeared to be cognizant of their problems, but that corrective actions plans must be seen to completion through effective oversight.
He also stated that personnel performance at the working level was crucial to long term improvement.
Hr. Perkins commented that there must be a sense of one team.
He pointed out that the Operations Department should be the lead and run the plant.
Operations must be critical and not be willing to live with problems.
Engineering and Maintenance should realize that they are tasked with supporting Operations.
gA should identify problems, and assure that corrective actions are effective.
Hr. Perkins then said that management must serve as a barrier to the occurrence of problems, and must have a
critical and intrusive nature with respect to assessing plant operations.
He concluded by stating that the NRC was looking forward to the Suture success of WNP-2 program initiatives and new personnel, but will insist on safety in current plant operatio Nr. Oxsen stated that he was pleased with the discussion, and that the Supply system has a lot of work ahead of them.
The meeting adjourned at 12:50 p.m.
Attachment:
Copy of slides used during the licensee's presentations
YVl'.P-2/I'.KCREGION V MANAGEMENT IREETING MARCH4, 1993 WASHINGTON PVBI IC POWER surprv svsTmc
ISSUES Equipment Failure Rates Industry Information Utilization Interorganizational Communication Problem Evaluations Procedural Compliance Audit Finding Responses Performance Improvement Efforts
CHRONOLOGY OF EVENTS - WNP-2 JANUARY21, 1993 - FEBRUARY 19, 1993 Date January 21, 1993 January 28, 1993 January 29, 1993 Janu0ary 30, 1993 January 31, 1993 January 31, 1993 January 31, 1993 Time 0946 2220 1729 1129 0206 1513 2156 Event Automatic Scram - Loss of Feedwater Pump resulting from deluge system flooding of feedwater electrical panel FaQure of FCV to run back Turbine balance shot Problem with fuse coordination DG 2 Voltage Regulator Repair; HPCS Emerg. Battety Repair Reactor Critical o
Manual Scram from 3% to Repair Steam Leak in cracked weld upstream of MS-V-239 Reactor Critical o
Manual Scram to correct Turbine Generator Vibration problems Reactor Critical Synchronized Generator to the Grid - Continue to have Unacceptable Twbiae Vibration Day
Februaty 1, 1993
"'241 Turbine OffLine hfanual Scram Correct Vibration Problems Repair Containment Valves which failed LLRTTest February 4, 1993 February 5, 1993 February 6, 1993 February 7, 1993 February 7, 1993 February 10, 1993 2201 0925 0947 0912 1812 1730 Reactor Critical Turbine On Line - Load to 60 hIwv o
Manual Scram from 31% - Failed transfer of Recircuhtion Pump to Fast Speed Reactor Critical Turbine Oa Line Automatic Scram & Unusual Event - Loss of Feedwater Pump due to electrical connector faVure on governor controVer.
16
20 February 11, 1993
"Management Time Out" called to assess Interrelationship of
events over the past 2-3 weeks and assure the readiness of IVNP-2 for startup Februaty 16, 1993 February 17, 1993 Februaty 19, 1993 0508 0953 1242 Reactor Critical Sychronized Generator to Grid - Loaded to 60 htwe Reactor Power 100%
27
TECHNICALSPECIFICATION VIOLATION (CEP-U-3A, 4A)
WHAT HAPPENED?
CEP-U-3A, 4A, failed LLRT on November 23, 1992.
Technical Specification 3.6.1.S required correction at next plant cold shutdown LCO and Problem Evaluation Request (PER) written, both specifying problem correction prior to restart from R-S Plant restarted on January 2S and January 31, 1993, without correction of problem
~CAU K Inadequate problem evaluation - Failed to correctly identify restart restraint from cold shutdown Lack of a questioning attitude - Caused the error to be missed by others involved in the review of the PER and LCO logbook prior to restart on January 2S and January 31
CORRECTIVE ACTI N CEP-V-3A, 4A, were repaired, retested and returned to operable status PPM 1.3.1 revised to provide more detailed direction regarding critical information that should be documented on LCO/INOP status sheets Individual involved in the problem has been disciplined Re-emphasized to organizations involved, the requirement for good interdepartmental communication and a continuous questioning attitude
FAILED RECIRCULATIONPUMP UPSHIFT WHAT HAPPENED?
Recirculation Pump 3 tripped on February 6, 1993, when it was being transferred to high speed Manual scram due to being in region of increased awareness and in an unanalyzed condition Evaluation determined that trip was due to a momentary low feed flow indication with recirculation pump hand switch in transfer position CAUSE
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Restraints developed by Supply System for recirculation pump shift may be too restrictive (32% power and analyzed rod pattern)
Modification of plant procedures without an adequate assessment of operating constraints that these changes represented Failure to learn from a previous recirculation pump trip Management oversight became too involved in decision process
CORRECTIVE ACTI N Re-evaluating restraints and procedural guidance for recirculation pump upshift Process for performing recirculation pump shift modified to include a more accurate method of monitoring feedwater flow.
Use low power interlock bypass switch to avoid the unintended instantaneous feed fiow trip Management Time Out re-emphasized the need to learn from lessons of the past and the importance of management maintaining the broad overview
HIGH PRESSURE CORE SPRAY (HPCS) BATTERY DEG&Q)ATION
'HAT HAPPENED?
HPCS battery charger tagged out under a clearance order HPCS battery not disconnected from its normal DC loads HPCS DG soakback oil pump (DC) continued to run, powered from the battery HPCS battery voltage decreased to -50 VDC over 26 hours3.009259e-4 days <br />0.00722 hours <br />4.298942e-5 weeks <br />9.893e-6 months <br /> WHY?
Personnel performance errors (lack of effective communications, questioning attitudes and attention to detail)
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CORC failed to communicate concern on the C.O.
Shift manager in Work Control assumed, without adequate technical basis, that, based on the duration of the job, the battery would not draw down.
Risk assessment, or any contingency/mitigation strategy, was not communicated to the Control Room (CR)
Inadequate second level review of C.O. by CR crew CR crew did not respond appropriately to the HPCS battery low voltage alarm Lack of "ownership" of the work through the implementation phase (Operations personnel typically perform well when they feel ownership of the activity)
RE ULTS Operability of the HPCS battery was affected C RRECTIVE ACTION TAKEN HPCS battery successfully recharged and returned to operable status t
Disciplinary action (Level 2) for all individuals involved.
Effective communication, attention to detail, and a more questioning attitude are key elements
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Allfuture pre-approved work requiring a clearance order will also require a formal "risk assessment"
'rocedure written for proper isolation of the HPCS SM-4 bus Changes to the forced outage process
TECHNICALISSUES Low Pressure Turbine Rotor Balancing Containment Exhaust Purge/Containment Supply Purge Valve Leakage Loss of Feed Pump B Reactor Recirculation Flow Control Valve Run-Back Evaluation
LOW PRESSUfUl TUM)INEROTOR BALANCE BACK R Ul'43 Low Pressure disc crack identified during the 19S7 refueling outage
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Low Pressure rotors replaced in June 1992 with state-of-the-art integral rotors resulting in 19 additional MWe ROTOR BALANCIN Balancing performed on initial startup limited to weights added to the jack shafts Prior to January 21,.1993, operating with two bearings at 7 and 4 mils Westinghouse recommended rotor balancing to reduce below 4 mils Added 48 ounces of weight in two locations on Low Pressure No. I, Bearings 3 and 4, on January 23
On roll-up on January 30, vibration exceeded previous readings by 1 to 3 mils Amplitude and phase angle indicated the weight was 180'rom where it was expected The decision was made to reverse the weights (scram, break vacuum)
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Following restart on January 31, vibration was again high The decision was made to scram, break vacuum and remove both weights-restoring the turbine to pre-January 21 conditions PROBLEM EVALVATION/DECISIONPROCESS The decision to reverse the weights on January 31 was made without complete understanding of the problem Vendor understanding of factors affecting machines of this size is limited CORRECTIVE ACTIONS Current efforts are underway with the vendor to determine the effect of pedestal/bearing interface, shaft run-out, and temperature effects in'rder to complete the balance process in R-8 Recognize and emphasize the need for management to maintain a questioning attitude and avoid unnecessary challenges based on limited knowledge
CSP/CEP BUTTERFLY VALVELEAKAGEPERFORMANCE SYSTEM OVERVIEW See Figure 1 - Primary Containment Supply and Exhaust Purge VALVEDESCRIPTION
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BODY CSP-V-1, -2 CEP-V-IA, -2A CSP-V-3, -4 CEP-V-3A, -4A 30" DIAlMETERBIF BUTTERFLY 24" DIAMETERBIF BUTTERFLY PERATOR Millerair operator, air to open, spring to close (fail close on loss of air)
EAL TYPE/CONFI URATI N See Figure 2 Originally supplied with "VITON"seals and later changed to
"BUNA-N"seals by Supply System for increased sealing capability New seals installed in R-4 are "NITHLLE"which is harder, more tear resistant, and have lower rubbing friction compared to old seals
FAILUREHI T RY PRI R T R-4 UTA E W TYLE EA IN TALLED Multiple failures (LLRT) of BUNA-Nseals on all valves except CSP-V-3 and CSP-V-4. LLRT failures primarily due to seal tearing due to rubbing friction. These seal failures were not
. correctable via operator linkage adjustment Seal life was random but typically less than two operating cycles NEW EAL DEVEL PMENT
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Development work began in 1988 to select new seal material and improve retaining ring design
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Desire for tougher material to correct tearing problem
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Better clamping to reduce seal "roll"when riding up the seat Old seal cross-sectional configuration was deemed inadequate for the tight sealing service application (containment isolation)
Supply System/Enertech developed new seal shape and corresponding retaining ring. Tested new seal configuration on like valve in maintenance training facility with good results (2600 cycles)
New seal/retaining ring design issued as EMS 30063, Revision 0, for installation in R-4 (1989)
OTHER CHANGES IMPLEMENTED TO-DATE
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Equipment Modification Specification (EMS) Development
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Field installation of new seals in R-4 revealed minor configuration differences between test valve and CSP/CEP valves.
Development of installation techniques continued on plant valves resulting in four revisions to the EMS:
Revisions I, 2, 3: Modify installation techniques to ensure good sealing characteristics Revision 4: Added three holes between each retaining ring stud hole to allow seal to "flow"when compressed without scalloping
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A new LLRT failure mechanism was later identified where leakage is around back of seal and out retaining ring stud holes. EMS 30063, Revision 5, was issued and implemented in R-6 (1991) adding Dow Corning sealant to backside of seal, and refined seal compression based on seal-to-seat interference
FAILURE HI Y RY F NEW DE I N NOTE: In all cases below, LLRT failures were due to one of two valves in series, such that containment integrity was maintained via the other valve LLRT results are mixed since new seal installation in 19S9:
CSP-V-1,-2:
Tested 18 times since R-4 with three failures:
Failed LLRT in December 1990 - Corrected by linkage adjustment Failed LLRT in May 1991 (R-6) - Corrected by linkage adjustment Failed LLRT in November 1991 - Corrected by linkage adjustment CSP-V-3,-4:
Tested.16 times since R-4 with no failures CEP-V-IA,-2A: Tested 26 times since R-4 with two failures:
Failed LLRT in January 1990 - Corrected by linkage adjustment Failed LLRT in May 1991 (R-6) - Corrected, by seal replacement
CEP-V-3A,-4A: Tested 23 times since R-4 with six failures:
Failed LLRT in May 1990 - Corrected by linkage adjustment Failed LLRT in August 1990 - Corrected by linkage adjustment Failed LLRT in May 1991 (R-6) - Corrected by seal replacement Failed LLRT in September 1992 - Corrected by linkage adjustment Failed LLRT in November 1992 - Corrected by linkage adjustment Failed LLRT in February 1993 - Corrected by seal adjustment NOTE: Correction of LLRT failures via linkage adjustment does not imply that linkage position was cause of problem.
Adjustment of linkage reconfigures seal to reduce leakage behind seal/disc interface Recent g<'ebruary 1993) failure on CEP-V-4A, attributed to leakage behind seal due to relaxation of seal compression due to permanent set of elastomer
INCREASED FRE VENCY TE TIN A decision was made to test valves 1, 2, 1A, 2A, 3A, and 4A following each use, as well as the technical specification-required six-month test in September 1991, in response to failures of the valves FUTURE PLANS Based on positive determination of failure mechanism, EMS 30063 is being revised to incorporate a seal modification and addition of Bellville washers to eliminate leakage around back of seal.
This modification willbe implemented R-8.
(See Figure 3 for new seal design)
R-8 seal modifications are expected to solve the leakage reliability issue. Ifthe seal modifications are ineffective, long range plans are to replace the existing CSP/CEP BIF butterfly valves with a new valve design, utilizing metal-to-metal seats
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CURRENT SEAL DESIGN FIGURE 2: ORIGINALAND CURRENT SEAL DESIGN
VALVE DISC NITRILE SEAL RETAINING RING RETAINING STUD~
AND LOCK NUT
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NEW BELLVILLE WASI-IER NEW RAISED "HUMP" Ol'l HACK OF SEAL VALVE SEAT VALVE BODY~
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COI'll 'f( l3BA I lAI'J l-II'-. Il. I'J Cl IANGl:. f.Olx IxO
FEED WATER CONIROL FAILURES EVENT On February 10, RF'W Turbine 13 went to idle with the plant at 100Vo.due to corrosion of a pin in an amphenol connector resulting in a low level scram BACKGROUI'G)
Feed water turbine actuators have failed in 19S9 and 1991 due to similar cause Although we have experienced numerous other feed pump trips since initial startup this was the first plant shut down experienced because of this condition EFFECT This non-safety control system sub component inadequacy has adversely impacted plant availability and has provided an unwanted challenge to safety systems
PROBLEM EVALUATI N PR C
This effect was traced to the physical location of the connector and the corrosive environment which exists in the %oodward actuator
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This condition was evaluated by the vendor and our root cause process with the result that the entire actuator was to have been exchanged every two years.
The activity was scheduled by our scheduled maintenance for Aprilof this year
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This corrective action was inadequate in the determination of the mean time between failures and did not account for the removal of the corrosion mechanism CORRECTIVE ACTI N Both RFW turbine actuators were changed to assure operability until R-8 A technical evaluation is being performed to determine how to address the prevention of corrosion of the connector to be implemented during R-8 Emphasis willbe placed on the need to solve the cause of
-. problems rather than the addressing only of symptoms
REACTOR RECIRCULATIONVALVECOKZROL FAILURES BACKGR UI'W Reactor recirculation system valves have failed to mitigate impending shutdowns on a loss of one feed pump and coincident low reactor level in 1989 and 1993 Our investigation found a less than optimal gain setting existed in the velocity feedback signal conditioning amplifier
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The hydraulic power unit volume limiters were set at a rate of stroke limit below that of the electronic speed limiters EFFECT Non-safety control system sub component inadequacies have adversely impacted plant availability and have provided unwanted challenges to safety PROBLEM EVALUATIONPROCESS These effects were traced to two causes:
Inadequate direction concerning the adjustment of system components o
Inadequate post modification or maintenance test result review
CORRECTIVE ACTI N System engineers have been empowered to exercise more control over their systems and have been afforded more time to perform their responsibilities.
~
The engineering test procedure has been modified to assure the correct parameters are evaluated after maintenance is performed
IDEN'IIblZDWEAKNESSES Failure to resolve problems the first time (e.g., CEP/CSP, RFW
.turbine failure)
Management overview effectiveness inadequate (e'.g., LP turbine, RFW turbine failure)
Proceeding with problem resolution without fully understanding the problem (e.g., LP turbine balancing, RFW turbine failure, RRC flow control valves)
IMPROVEMENTNEEDED FROM MANAGEMENTTHEIR OUT:
Emphasize the need to maintain a "questioning attitude" At all levels of the organization, strive to solve the problem and not treat the symptom Avoid risk decisions where possible/evaluate risks and minimize impact
ISSUES Frequency and Recurrence of Equipment Failure Effectiveness of Problem Assessment and Root Cause Determinations Effectiveness of Interorganizational Communication Effectiveness in Assuring Corrective Actions Resolve Identified Problems
OVERCURRENT/UNDERVOLTAGE COORDINATION PROBLEM
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Faults on critical switchgear SM-7 (-S) cause the undervoltage relays to transfer the bus before the overcurrent protection locks out closure of backup sources When operating both critical switchgear on TR-S or TR-B, the faulted bus could delay transfer to the diesel on the non-fault redundant critical switchgear HOW FOUI'W Possibility discussed during 1992 EDSSFI
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Based on existing calculations, appeared that overcurrent and undervoltage relays for normal supply could coordinate
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Did not review backup source coordination Calculation improvement program
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Recently completed short circuit calculations In process of completing relay coordination study o
PER was being prepared and meeting held prior to plant trip
ACTI N PLAN T
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Design Engineering
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Two teams working around-the-clock to prepare design change
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Plant TechnicalMaintenance involved in the design
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Plant Technical
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Preparation of work instructions
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Preparation and conduct of retest requirements
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Evaluation of operability
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Maintenance
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Staged equipment and parts Pre-calibrated time delay relays o
Installed design change
Primary undervoltage bus protection Changed the 2-second time delay relays on the primary bus undervoltage protection to 3 seconds, which trip normal Supply Breaker 7-1 (8-3)
This ensures overcurrent relays trip and lock out other sources prior to undervoltage relay operation Other timers in the scheme were decreased by 1 second to keep all other actions at the same relative time TR-3 undervoltage protection Added new 3.5 second timers on 69% undervoltage trip of 3-7 (3-8) breakers This ensures the overcurrent relays on B-7 (3-8) trip prior to the TR-B undervoltage relays for bus faults on SM-7 (SM-8)
SUMVTARY Electrical calculation improvement program is identifying and resolving problems Problem was identified and action occurring prior to plant scram Time from problem identification to resolution was minimal due to teamwork between organizations Faults on SM-7 (SM-8) willbe cleared by overcurrent protection and backup sources willbe locked out Isolating faulted vital busses will ensure availability of preferred and backup power sources to the redundant bus Calculations are nearly complete to ensure coordination of all breakers to the 480 volt level Future design changes (planned for R-9) willspeed up overcurrent protection
DG-2 VOLTAGE REGULATOR HI T RY History of slow voltage buildup on the generator challenging the 10-second start requirement Vnique design to W%'-2 R-6 DESI N CHAN E T INCREA E FIELD FLASH TIME Precision solid state voltage relay installed DG-2 only Not enough contacts on new relay so left old scheme in to enable voltage regulator Design was reviewed and interaction discussed with the voltage regulator vendor
N VEMBER 30 FAILURE
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Voltage came up slowly, stalled for a duration, and then recovered normally
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Failure would not repeat itself Decision was made to change out the voltage regulator module as being the most likely cause
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DG starts (8 seconds Increased surveillance frequency to weekly Lessons learned:
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Need to increase number of personnel with voltage regulator knowledge
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Testing of spare parts by vendor was questionable
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Better instrumentation would assist in troubleshooting efforts
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Difficultto find intermittent problems
VENDOR TRAINING
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Learned about via discussions with other utilities Include personnel from Maintenance (2), Plant Technical (1), and Engineering (2)
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Training on theory and troubleshooting Specifically discussed November failure ANUARY23 FAILURE As voltage increased, it paused at 3500 volts before continuing to rated voltage.
Total time to reach rated voltage was about 16 seconds Troubleshooting
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Management with voltage regulator knowledge were used in overview function
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Troubleshooting teams made up of newly trained personnel from Plant Technical, Maintenance, and Design Engineering were formed Better instrumented for operation of the voltage regulator
Contacted EMD User Group and voltage regulator manufacturer Findings Failure would repeat randomly
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Voltage pause on startup occurred when field flash was still on and voltage regulator was enabled.
As soon as field flash was terminated, voltage would ramp up at normal rate
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Decision was made to change the design to avoid overlap of field flash when the voltage regulator is enabled (original design)
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Exact cause of this interaction was not determined.
Additional testing is planned Suspected Cause
~
Held fiash leads and voltage regulator reference voltage leads to the motorized potentiometer are routed in the same bundle
~
Induced voltages on the reference signal can cause the regula'tor to think the generator voltage is too high SUMMARY The R-6 design change introduced an intermittent failure Decision to replace the most likely component led to the January failure We believe we have found the problem but additional testing is planned Good team effort during recent troubleshooting and design changes
FEEDPUMP TRIP DUE TO FIRE PROTECTION DELUGE WHAT HAPPENED?
~
Feedwater pump tripped due to painter actuation of manual pull station CAUSE Lack of personnel attention to details by painter, his lead man and their supervisor Lack of rigor to control painting program'mplementation CORRECTIVE ACTION Suspended all painting activities until short-term corrective action is completed Implemented walkdown with Opeations to identify sensitive equipment before start of painting work Evaluation of lessons learned from other plant painting programs Initiating a sensitive equipment labeling program Discipline of painter, lead man and supervisor
MS V-239 LEAK REPAIR WHAT HAPPENED'?
Valve was repacked on January 23, 1993; failed to identify leak was from a cracked weld Plant shut down and placed in cold shutdown on January 29,
'1993 to weld repair MSV-239 CAUSE Incomplete problem identification CORRECTIVE ACTION Repaired leak by cutting and capping the drain line Initiated metallurgical analysis of failure Performed NDE on other three lines Emphasized to maintenance personnel the importance of accurately identifying and describing the problem to be fixed
RPV WATER LEVEL ISSUE TIMELINE JULY 22 JULY 29 JULY 29-31*
AUG 4*
AUG 12*
AUG 19 AUG 19*
AUG 28
NRC REQUESTS RRG ACTIVATION RRG PRESENTATION TO NRC BWROG MTG OF ALLUTILITIES COMPUTER FILE TO CAPTURE NEXT DATA RRG PLAN AND SCHEDULE TO NRC NRC ISSUES GL 92-04 EPC-II LTR ISSUES ON NOTCHING RRG GENERIC REPORT TO NRC SEPT 14*
SEPT 24*
SEPT 28*
SEPT 28*
OPERATOR REQUIRED READING ON 8/19 LTR BWROG LTR TO NRC (9/9 QUESTIONS)
WNP-2 LTR TO NRC (BWROG PROGRAM)
OPERATORS TRAINED ON 8/19 LTR OCT 14*
OCT 16*
OCT 19~
NOV 23*
DEC 11*
DEC 15 JAN 12*
JAN 18*
JAN 21*
JAN 22~
JAN 24*
JAN 25*
JAN 27*
BWROG MTG TEST CONDITIONS EPC-II LTR ISSUED BY DEPRESSURIZATION (RPV WATER LEVELTECHNIQUE)
WNP-2 EVALUATINGROUTING AND MOD OPTIONS
" OPERATOR REQUIRED READING ON 10/16 LTR EPC-II MTG - ACCEPTABLE TEST CRITERIA EPC-II VIDEO SHOWN TO NRC EPC-II MTG - DISCUSS IMPLEMENTATIONOF EPC LTRS TO UTILITIES OPERATORS TRAINED ON 11/16 LTR WNP-2 NOTCHING & DEGASSING OBSERVED OBTAINED NARROW RANGE NOTCHING DATA POC DISCUSSES WNP-2 NOTCHING ENGR INITIATESEVALOF DATAAND IMPACT WNP-2 TOOK DATATO RPV BWROG MTG FEB 3~
FEB 3 FEB 5*
FEB 9*
FEB 10*
FEB 12*
FEB 12*
OBTAINED COMPLETE NARROW RANGE NOTCH DATA NRC PUBLIC MTG AT PLYMOUTH, MA.
WNP-2 DISCUSSES DATA AT EPC-II MTG PRELIM RESULTS ON ENGR REVIEW DISCUSSED (ENGR',
TECH, OPNS, QA, LICENSING, TRAINING)
PLANT MGR BRIEFED ON MITIGATINGACTIONS SDC ISSUE IDENTIFIED, PER WRITTEN BCO WRITI'EN AND APPROVED WNP-2 PARTICIPATION
RPV WATER LEVEL INSTUMENTATION SAFETY FUNCTIONS REVIEWED 1.
HPCS HIGH LEVELTRIP 2.
RPS INIT. / RCIC HIGH LEVELTRIP / RHR ISOLATION 3.
LEVEL 2 ECCS (HPCS) INITIATION 4.
CONTAINMENTISOLATIONINITIATION 5.
POST ACCIDENT LEVEL MONITORING (MAINCONTROL ROOM / REMOTE SHUTDOWN / APPENDIX R)
6.
MSIV HIGH PRESSURE SCRAM INTERLOCK 7.
RPS INITIATION 8.
POST ACC1DENTPRESSURE MONITORING(MAINCONTROLROOM/ REMOTE SHUTDOWN / APPENDIX R)
9.
RFW HIGH LEVELTRIP 10.
MSLCS INITIATION 11.
ATWS INITIATION 12.
ECCS INITIATION 13.
ADS INITIATION 14.
POST ACCIDENT MONITORING (FUEL ZONE)
15.
SRV ACTUATION 16.
ECCS INJECTION VALVEINTERLOCK 17.
ATWS INITIATION 18.
POST ACCIDENT LEVEL MONITORING (SHUTDOWN RANGE)
19.
POST ACCIDENT LEVEL MONITORING (UPSET RANGE)
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RECOVERED VOLUME Ec CONDENSED VOLUME 175 150 125 CD K
Oz 100 O
C)DO~I
D O
CONDENSfD VOLUME RECOVERED VOLUME
25
0
10 TIMf(MIN)
20
REPEAT PROBLEMS
%'HAT HAPPENED~
CSP/CEP valve problems FWP governor control DG failures WHY?
Past QA assessments (audits, surveillances, and technical assessments)
have not identified or corrected weaknesses in our methods for identification (trending) and resolution (resource allocation) of repeat equipment problems Actions accepted by the Operating Event Analysis and Resolution (OEAR) (root cause) group and plant line staff as resolution to individual problems were not effective CORRECTIVE ACTION FPI root cause training for selected QA engineers and managers OEAR reviewers willbe more aggressive in asking for responses which correct repeat problems or elevating concerns on non-effective fixes to upper management Strengthen QA assessment processes so equipment trending and resolution is critical attribute evaluated in-depth on a regular basis
QUALITYASSURANCE COVERAGE WHAT HAPPENED?
Quality Assurance (QA) coverage of forced outage has been provided by plant QA alone WHY?
Past management direction has stressed specialization in work methods and areas covered.
This artificially erected barriers between groups and a separation from real time plant activities RESULTS Potentially caught HPCS battery problem earlier Potentially caught CSP/CEP valve rework needed CORRECTIVE ACTION A QA forced outage response team willbe designated from among all three assessment groups Additional training and clearer expectations for QA engineers on investigative approaches Improved coordination with all assessment groups reporting to one manager
WALEDOWNS WHAT HAPPENED?
Plant walkdowns on February 11-1Z were good team building exercises - provided thorough snapshot of current plant status WHY?
Allgroups involved had a clear common objective and realized the need to support this task
System Engineering
~
Design Engineering
Operations
Maintenance
Quality Assurance
RE T
Quality Assurance was able to react and provide 11 people to support walkdowns, as well as a team of 4 to evaluate the quality within a 4-hour period (request to action)
Assessment results indicate walkdowns were thorough and comprehensive and action was taken to resolve deficiencies noted Personnel involved believed the common approach built teamwork through sharing of individual knowledge FURTHER A TI N These walkdowns willbe continued on a periodic basis Management will seek other opportunities for promoting common objectives and building team approaches (e.g. FORT, formal 36 hourl3 dayl7 day forced outage schedule review)
ISSUES Effectiveness of Interorganizational Communications Effectiveness of Problem Evaluation
WNP-2 WORf( CONTROL ORGANlZATlONCHART OPERATIONS DIVISIONMANAGER G.O. SMITH WORK CONTROL MANAGER JOHN DABNEY SHIFT MANAGER MATRIXOPS. (SRO)
CLERK W. FRANK SCHEDULING SUPERVISOR B. BOND SCHEDULING*
1-3KhE2 2.
3.
1/2 TIME CLERK J. HATCH MAINTENANCE PROGRAMS ASSOCIATE ENG S.KRUEGER WORK CONTROL COORDINATOR 1. G. SHINDEHITE - MECH
{LEAD)
2. EHLERT - H.P.
4. REHFIELD - ELECT.
. IUIIKJLJ 7. HEXUhl - MAT.
C.O.R.C.
1. M. WOODS (R.O.)
2. J. WUNDERLICH (E)
~ MATRIXFROh1 OPS MATRIXFROM PROJECTS 92-2139
HOW DECISIONS ARE MADE Normal daily work Past forced outages Emergent work
FORCED OUTAGE SCHEDULE/OVERVIEW Poorly planned emergent work Proper decision, failure to execute Loss of focus on outage recovery
5G&lAGENIENTTIME OUT Reasons for the Time Out Results of the Time Out
FORCED OUTAGE RECOVERY TEAM PLANT MANAGER OPERATIONS DIVISION MANAGER TECHNICAL DIVISION MANAGER H.P.
DIVISION MANAGER MAINTENANCE DIVISION MANAGER F.O.
MANAGEMENT 1.
2.
3.
OPERATIONS MAINTENANCE TECHNICAL CHEMISTRY H.P./ALARA WORK CONTROL QUALITY ASSURANCE ENGINEERING 92-2139. A
5'ORCED OUTAGE SCHEDULES 36 Hr. Schd.
72 Iir. Schd.
possible break condenser vacuum 7 Day Schd.
possible DiW entry
CW&lGE 1VL&lAGEMENTEVALUATIONOF EMERGENT WORK
EMERGENT
'- WORK INITIATE WORK DOC.
YES P RI.1/A YES OUTAGE TASK P RI.1/A YES EVALUATE" OM/NCM PLAN/SCHD WORK YES R-8 TASK NO BACKLOG o EXTEND WIHDOW o ADDITIONALRESOURCES o ANOTHER WINDOW EVALUATIONCRITERIA PARTS ICOST RF SOURCES RQD IMPACT OH WINDOW IMPACT OH OUTAGE PLANT RELIABILITY TECH SPEC IMPACT ALARA IMPACT
MANAGEMENTTIME OUT RESULTS Change Management Process Forced, Outage Organization Management Policy/Execution of Management Policy Forced Outage Policy Communicate
R-8 OUTAGE OVERVXEW Shortest planned outage to-date at WNP-2 (45 days)
Major Projects:
~
Main steam relief valve replace/repair (12 of 18)
~
Motor-operated valve program:
70 refurbishments 32 baselines 29 Delta-P tests
~
Spray pond drain/inspect
Jet pump cleaning Outage readiness Outage planning team
Scope control Outage organization Work package status
J'