Operational Challenges During a Dual-Unit Transient ML031070483 Person / Time Site:
Beaver Valley , Millstone , Hatch , Monticello , Calvert Cliffs , Dresden , Davis Besse , Peach Bottom , Browns Ferry , Salem , Oconee , Mcguire , Nine Mile Point , Palisades , Palo Verde , Perry , Indian Point , Fermi , Kewaunee , Catawba , Harris , Wolf Creek , Saint Lucie , Point Beach , Oyster Creek , Watts Bar , Hope Creek , Grand Gulf , Cooper , Sequoyah , Byron , Pilgrim , Arkansas Nuclear , Braidwood , Susquehanna , Summer , Prairie Island , Columbia , Seabrook , Brunswick , Surry , Limerick , North Anna , Turkey Point , River Bend , Vermont Yankee , Crystal River , Haddam Neck , Ginna , Diablo Canyon , Callaway , Vogtle , Waterford , Duane Arnold , Farley , Robinson , Clinton , South Texas , San Onofre , Cook , Comanche Peak , Yankee Rowe , Maine Yankee , Quad Cities , Humboldt Bay , La Crosse , Big Rock Point , Rancho Seco , Zion , Midland , Bellefonte , Fort Calhoun , FitzPatrick , McGuire , LaSalle , 05000204 , Fort Saint Vrain , Shoreham , Satsop , Trojan , Atlantic Nuclear Power Plant , Crane Issue date:
06/15/1993 From:
Grimes B Office of Nuclear Reactor Regulation To:
References IN-93-044 , NUDOCS 9306080170Download: ML031070483 (8)
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Beaver Valley ,
Millstone ,
Hatch ,
Monticello ,
Calvert Cliffs ,
Dresden ,
Davis Besse ,
Peach Bottom ,
Browns Ferry ,
Salem ,
Oconee ,
Mcguire ,
Nine Mile Point ,
Palisades ,
Palo Verde ,
Perry ,
Indian Point ,
Fermi ,
Kewaunee ,
Catawba ,
Harris ,
Wolf Creek ,
Saint Lucie ,
Point Beach ,
Oyster Creek ,
Watts Bar ,
Hope Creek ,
Grand Gulf ,
Cooper ,
Sequoyah ,
Byron ,
Pilgrim ,
Arkansas Nuclear ,
Braidwood ,
Susquehanna ,
Summer ,
Prairie Island ,
Columbia ,
Seabrook ,
Brunswick ,
Surry ,
Limerick ,
North Anna ,
Turkey Point ,
River Bend ,
Vermont Yankee ,
Crystal River ,
Haddam Neck ,
Ginna ,
Diablo Canyon ,
Callaway ,
Vogtle ,
Waterford ,
Duane Arnold ,
Farley ,
Robinson ,
Clinton ,
South Texas ,
San Onofre ,
Cook ,
Comanche Peak ,
Yankee Rowe ,
Maine Yankee ,
Quad Cities ,
Humboldt Bay ,
La Crosse ,
Big Rock Point ,
Rancho Seco ,
Zion ,
Midland ,
Bellefonte ,
Fort Calhoun ,
FitzPatrick ,
McGuire ,
LaSalle ,
05000204 ,
Fort Saint Vrain ,
Shoreham ,
Satsop ,
Trojan ,
Atlantic Nuclear Power Plant ,
Crane Category:NRC Information Notice
[Table view] The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:05000204]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] OR [[:Crane]] </code>.
Contents
1 NUCLEAR REGULATORY COMMISSION 2 WASHINGTON D.C. 20555 3 Addressees
3.1 DescriDtion of Circumstances 3.2 At the time of the event the control 3.3 Control room simulator training scenarios had not 3.4 This was a direct result of the crew 3.5 The decision not to use the emergency 3.6 Related Generic Communications 3.7 Brian K. Grimes, Director 3.8 Office of Nuclear Reactor Regulation 3.9 Shaeffer, RII 3.10 D. R. Desaulniers, NRR 3.11 List of Recently Issued NRC Information Notices 3.12 Lubrication OI s in 3.13 FVaTes Manufactured by 3.14 One Hour Fire Endurance 3.15 Ceramics Kaowool 3M 3.16 Barrier Systoes 3.17 Fire Endurance Test 3.18 Barrier Material 3.19 Radiation Beas from 3.20 Imedequote Testing of 3.21 Featurs Actuation 3.22 Valve Operator Housing 3.23 Nortifications, Reports 3.24 Cause Failure Events 3.25 All holders of OLs or CPs 3.26 All holders of OLs or CPs 3.27 All holders of OLs or CPs 3.28 All holders of OLs or CPs 3.29 All holders of OLs or CPs 3.30 All holders of OLs or CPs 3.31 All holders of OLs or CPi 3.32 All U.S. Nuclear Regulatory 3.33 All holders of OLs or CPs 3.34 Construction Per1it 3.35 NUCLEAR REGULATORY COMMISSION 3.36 OFFICIAL BUSINESS 3.37 FIRST CLASS MAIL 3.38 PFUNTED ON RECYCLED PAPER 3.39 Original Isgned by 3.40 Brian K. Grimes, Director 3.41 Office of Nuclear Reactor Regulation 3.42 Shaeffer, RII 3.43 Desaulniers, NRR 3.44 List of Recently Issued NRC Information Notices 3.45 Brian K. Grimes, Director 3.46 Office of Nuclear Reactor Regulation 3.47 Shaeffer, Region II 3.48 Desaulniers, NRR 3.49 List of Recently Issued NRC Information Notices 3.50 Brian K. Grimes, Director 3.51 Office of Nuclear Reactor Regulation 3.52 Shaeffer, Region II 3.53 D. R. Desaulniers, NRR 3.54 List of Recently Issued NRC Information Notices 3.55 RII CONCURRENCE OF PROPOSED IN 3.56 Thanks, Jack
NUCLEAR REGULATORY COMMISSION OFFICE OF NUCLEAR REACTOR REGULATION
WASHINGTON D.C. 20555 June 15, 1993 NRC INFORMATION NOTICE 93-44: OPERATIONAL CHALLENGES DURING A DUAL-UNIT
TRANSIENT
Addressees All holders of operating licenses or construction permits for nuclear power
reactors.
PurDose
The U.S. Nuclear Regulatory Commission (NRC) is issuing this information
notice to inform addressees of an event during which an atypical shift
staffing level and lack of familiarity with the tasks to be performed in that
shift configuration affected the ability of the control room operating shift
to respond to the event. It is expected that recipients will review the
information for applicability to their facilities and consider actions, as
appropriate, to avoid similar problems. However, suggestions contained in
this information notice are not NRC requirements; therefore, no specific
action or written response is required.
DescriDtion of Circumstances On December 31, 1992, a dual-unit reactor trip initiated by an electrical
fault in the switchyard occurred at the Sequoyah Nuclear Plant, Units 1 and 2 at Sequoyah share a common control room.
At the time of the event the control room reactor operator staffing was the minimum allowed by the plant Technical
Specifications (TS); shift staffing consisted of five licensed senior
operators (the shift operations supervisor, one assistant shift operations
supervisor for each unit, the shift technical advisor , and an additional
senior operator) and three reactor operators - two assigned to Unit 1 and one
assigned to Unit 2. The NRC inspection team investigating the event concluded
that the Unit 2 response to the event, with one reactor operator, was hampered
by lack of adherence to procedures, operator errors, and an unnecessary
cooldown of the reactor coolant system (RCS ) after the reactor trip . The
Unit 1 response to the same event, with two reactor operators, was normal.
Discussion
An NRC inspection team reviewed the effects of the Unit 2 staffing level
during the event with regard to the crew's ability to stabilize the unit after
the reactor trip occurred. The inspection team concluded that the Unit 2 staffing level delayed the recovery of plant systems, contributed to erroneous
decisions made by the assistant shift operations supervisor (ASOS), and
93060801VO
f33o(JISo
t/r,0t
SIle-/
IN 93-44 June 15, 1993 overburdened and challenged the crew's ability to perform tasks in the manner
in which it was trained.
Control room simulator training scenarios had not been conducted using only one reactor operator.
Although the normal shift staffing and training consisted of two
reactor operators for each unit, licensee operational staffing practices
resulted in the frequent use of one reactor operator for one of the units.
The licensee used this reduced staffing configuration 12 times in
December 1992. In this configuration, with the dual-unit transient , the
single reactor operator performed all of the recovery evolutions for the unit
as directed by the ASOS in charge of the unit.
Because of delays caused by the one reactor operator performing primary and
secondary system recovery evolutions, as required by the applicable recovery
procedures, an RCS cooldown resulted.
This was a direct result of the crew not adequately controlling auxiliary feedwater after the reactor trip .
The
atypical staffing level also contributed to problems involving the decision of
the assistant shift operations supervisor to use the normal-batch borate
process in response to the cooldown rather than the emergency borate process
as required by the emergency procedure.
The decision not to use the emergency borate process was made, in part, because of the reluctance of the assistant
shift operations supervisor to commit the one reactor operator to the
emergency borate process, which restricts the operator's attention to
monitoring only that activity.
As a corrective action to prevent recurrence, the licensee implemented revised
administrative controls to ensure that the control room staffing will be
maintained at two reactor operators for each operating unit. The need for
additional training at minimum staffing levels is being evaluated by the
licensee.
Related Generic Communications 1.
IN 85-80 , "Timely Declaration of an Emergency Class, Implementation of
an Emergency Plan , and Emergency Notifications," dated October 15, 1985
2.
IN 91-77 , "Shift Staffing at Nuclear Power Plants," dated November 26,
1991
IN 93-44 June 15, 1993 This information notice requires no specific action or written response.
If
you have any questions about the information in this notice, please contact
one of the technical contacts listed below or the appropriate Office of
Nuclear Reactor Regulation (NRR ) project manager.
Brian K. Grimes, Director Division of Operating Reactor-Support
Office of Nuclear Reactor Regulation Technical contacts:
S. M.
(615)
Shaeffer, RII 842-8001
D. R. Desaulniers, NRR (301) 504-1043 Attachment:
a
dgtil0l5
List of Recently Issued NRC Information Notices LIST OF RECENTLY
ISSUED
\\_2 NRC INFORMATION
NOTICES
I '
a
Notice Ib.
Subject
93-43 Use of Inappro
te
Lubrication OI s in Sefety-Rolat d Applications
93-42 Failure of Anti-Rotation
Keys in Motor-Operated
FVaTes Manufactured by 93-41
One Hour Fire Endurance Test Results for Thermal
Ceramics Kaowool 3M Ctany FS-195 and
311 Company Intern E-SO
Barrier Systoes 93-40
Fire Endurance Test Results for Thereal
Ceramics FP-60 Fire
Barrier Material 93-39
Radiation Beas from Power Reactor Dialog-
1csl Shields
93-38
Imedequote Testing of Engineered Safety
Featurs Actuation Systmn
93-31 Eyobolts with Indeter- Minote Properties In- stalled In tleitorque
Valve Operator Housing Covers
93-36
Nortifications, Reports and Records of Nisd1ni- istrations
93-3S
Insights from Comon-
Cause Failure Events --
Issua
ssued to
06/10/93
All holders of OLs or CPs for nuclear power reactors.
06/09/93
All holders of OLs or CPs for nuclear Power reactors.
05/28/93
All holders of OLs or CPs for nuclear power reactors.
0O/26/93
All holders of OLs or CPs for nuclear power reactors.
09/25/93
All holders of OLs or CPs for nuclear power reactors.
05/24/3
All holders of OLs or CPs for nucleur power reactors.
I
05/19/93
All holders of OLs or CPi for nuclear power reactors.
OS/07/93
All U.S. Nuclear Regulatory Cosmission Medical
licensees.
OS/12/93
All holders of OLs or CPs for nuclear power plants
(UPP )'.
OL
LIog
Lcense
tP -
Construction Per1it UNITED STATES
NUCLEAR REGULATORY COMMISSION WASHINGTON , D.C. 20555-0001
OFFICIAL BUSINESS PENALTY FOR PRIVATE USE, $300
FIRST CLASS MAIL POSTAGE AND FEES PAID
USNRC
PERMIT NO. G-67
PFUNTED ON RECYCLED PAPER IN 93-44 June 15, 1993 This information notice requires no specific action or written response.
If
you have any questions about the information in this notice, please contact
one of the technical contacts listed below or the appropriate Office of
Nuclear Reactor Regulation (NRR ) project manager.
Original Isgned by Brian K. Grime§
Brian K. Grimes, Director Division of Operating Reactor Support
Office of Nuclear Reactor Regulation Technical contacts:
S. M.
(615)
Shaeffer, RII 842-8001 D. R.
(301)
Desaulniers, NRR 504-1043 Attachment:
List of Recently Issued NRC Information Notices RGallo
BBoger
05/21/93
05/21/93
FHebdon
06/02/93
GMarcus
06/04/93
for
EMerschoff
05/28/93
'9
06// o/93
TJKim
05/28/93
MMejac
05/24/93 DOCUMENT NAME: 93-44.IN
IN 93-XX
June XX, 1993 This information notice requires no specific action or written response. If
you have any questions about the information in this notice, please contact
one of the technical contacts listed below or the appropriate Office of
Nuclear Reactor Regulation (NRR ) project manager.
Brian K. Grimes, Director Division of Operating Reactor Support
Office of Nuclear Reactor Regulation Technical contacts:
S. M.
(615)
Shaeffer, Region II 842-8001 D. R.
(301)
Desaulniers, NRR 504-1043 Attachment:
List of Recently Issued NRC Information Notices RGallo
BBoger
05/21/93
05/21/93
FHebdon
06/02/93
for
EMerschoff
05/28/93
TJKim
05/28/93
MMejac
05/24/93 OGCB:DORS
GMarcus qW4
06/+ /93--
DORS:NRR
BGrimes
06/ /93 DOCUMENT NAME: SEQUOYAH.INF
IN 93-XX
May XX, 1993 This information notice requires no specific action or written response. If
you have any questions about the information in this notice, please contact
the technical contact listed below or the appropriate Office of Nuclear
Reactor Regulation (NRR ) project manager.
Brian K. Grimes, Director Division of Operating Reactor Support
Office of Nuclear Reactor Regulation Technical contact:
S. M.
(615)
Shaeffer, Region II 842-8001
D. R. Desaulniers, NRR (301) 504-1043 Attachment:
List of Recently Issued NRC Information Notices File Name: SEJWOYAH.INF
ConcurentU
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o~fiO 9 PD
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05/ /93 DORS:NRR
BGrimes
05/ /93
From:
To:
Date:
Subject:
Richard V. Crlenjak
(RVC)
TJK3 Friday, May 28, 1993
1:01 pm
RII CONCURRENCE OF PROPOSED IN Region II has completed a review of the proposed Information
Notice, OPERATIONAL CHALLENGES DURING A DUAL-UNIT TRANSIENT .
We
have no further comments and concur with the proposed IN.
Should you need any additional info let
me know.
Thanks, Jack cc:
WEH,
PJK1, SMS,
AFG, JRJ, TAP,
EWM
list Information Notice 1993-01, Accuracy of Motor-Operated Valve Diagnostic Equipment Manufactured by Liberty Technologies 4 January 1993 Information Notice 1993-02, Malfunction of a Pressurizer Code Safety Valve 4 January 1993 Topic Loop seal Information Notice 1993-04, Investigation and Reporting of Misadministrations by the Radiation Safety Officer 7 January 1993 Topic Uranium Hexafluoride Overexposure Information Notice 1993-05, Locking of Radiography Exposure Devices 14 January 1993 Topic Uranium Hexafluoride Inattentive Information Notice 1993-06, Potential Bypass Leakage Paths Around Filters Installed in Ventilation Systems 22 January 1993 Information Notice 1993-07, Classification of Transportation Emergencies 1 February 1993 Information Notice 1993-08, Failure of Residual Heat Removal Pump Bearings Due to High Thrust Loading 1 February 1993 Topic Probabilistic Risk Assessment Information Notice 1993-09, Failure of Undervoltage Trip Attachment on Westinghouse Model DB-50 Reactor Trip Breaker 2 February 1993 Topic Commercial Grade Information Notice 1993-10, Dose Calibrator Quality Control 2 February 1993 Topic Uranium Hexafluoride Information Notice 1993-11, Single Failure Vulnerability of Engineered Safety Features Actuation Systems 4 February 1993 Information Notice 1993-12, Off-Gassing in Auxiliary Feedwater System Raw Water Sources 11 February 1993 Information Notice 1993-13, Undetected Modification of Flow Characteristics in High Pressure Safety Injection System 16 February 1993 Information Notice 1993-14, Clarification of 10 CFR 40.22, Small Quantities of Source Material 18 February 1993 Information Notice 1993-15, Failure to Verify the Continuity of Shunt Trip Attachment Contacts in Manual Safety Injection and Reactor Trip Switches 18 February 1993 Information Notice 1993-16, Failures of Not-Locking Devices in Check Valves 19 February 1993 Topic Anchor Darling Flow Induced Vibration Information Notice 1993-17, Safety Systems Response to Loss of Coolant and Loss of Offsite Power 25 March 1994 Topic Loss of Offsite Power Backfit Water hammer Information Notice 1993-18, Portable Moisture-Density Gauge User Responsibilities During Field Operations 10 March 1993 Topic Moisture Density Gauge Moisture-Density Gauge Stolen Information Notice 1993-19, Slab Hopper Bulging 17 March 1993 Topic Hydrostatic Information Notice 1993-20, Thermal Fatigue Cracking of Feedwater Piping to Steam Generators 24 March 1993 Topic Thermal fatigue Information Notice 1993-21, Summary of NRC Staff Observations Compiled During Engineering Audits or Inspections of Licensee Erosion/Corrosion Programs 25 March 1993 Topic Weld Overlay Reactive Inspection Information Notice 1993-22, Tripping of Klockner-Moeller Molded-Case Circuit Breakers Due to Support Lever Failure 26 March 1993 Topic Commercial Grade Information Notice 1993-23, Weschler Instruments Model 252 Switchboard Meters 31 March 1993 Topic Commercial Grade Information Notice 1993-24, Distribution of Revision 7 of NUREG-1021, Operation Licensing Examiner Standards 31 March 1993 Topic Job Performance Measure Information Notice 1993-25, Electrical Penetration Assembly Degradation 1 April 1993 Information Notice 1993-26, Grease Soldification Causes Molded-Case Circuit Breaker Failure to Close 31 January 1994 Information Notice 1993-27, Level Instrumentation Inaccuracies Observed During Normal Plant Depressurization 8 April 1993 Topic Reactor Vessel Water Level Information Notice 1993-28, Failure to Consider Loss of DC Bus in the Emergency Core Cooling System Evaluation May Lead to Nonconservative Analysis 9 April 1993 Topic Loss of Offsite Power Fuel cladding Information Notice 1993-29, Problems with the Use of Unshielded Test Leads in Reactor Protection System Circuitry 12 April 1993 Information Notice 1993-30, NRC Requirements for Evaluation of Wipe Test Results; Calibration of Count Rate Survey Instruments 12 April 1993 Information Notice 1993-31, Training of Nurses Responsible for the Care of Patients with Brachytherapy Implants 13 April 1993 Topic Brachytherapy Information Notice 1993-32, Nonconservative Inputs for Boron Dilution Events Analysis 21 April 1993 Topic Shutdown Margin Information Notice 1993-33, Potential Deficiency of Certain Class Ie Instrumental and Control Cables 28 April 1993 Information Notice 1993-33, Potential Deficiency of Certain Class IE Instrumental and Control Cables 28 April 1993 Information Notice 1993-34, Potential for Loss of Emergency Cooling Function Due to a Combination of Operational and Post-LOCA Debris in Containment 6 May 1993 Topic Brachytherapy Information Notice 1993-35, Insights from Common-Cause Failure Events 12 May 1993 Topic Probabilistic Risk Assessment Information Notice 1993-36, Notifications, Reports, and Records of Misadministrations 7 May 1993 Topic Brachytherapy Information Notice 1993-37, Eyebolts with Indeterminate Properties Installed in Limitorque Valve Operator Housing Covers 19 May 1993 Information Notice 1993-38, Inadequate Testing of Engineered Safety Features Actuation Systems 24 May 1993 Information Notice 1993-39, Radiation Beams From Power Reactor Biological Shields 25 May 1993 Information Notice 1993-39, Radiation Beams from Power Reactor Biological Shields 25 May 1993 Information Notice 1993-40, Fire Endurance Test Results for Thermal Ceramics FP-60 Fire Barrier Material 26 May 1993 Topic Safe Shutdown Fire Barrier Fire Protection Program Information Notice 1993-41, One Hour Fire Endurance Test Results for Thermal Ceramics Kaowool, 3M Company FS-195 and 3M Company Interam E-50 Fire Barrier Systems 28 May 1993 Topic Safe Shutdown Fire Barrier Information Notice 1993-42, Failure of Anti-Rotation Keys in Motor-Operated Valves Manufactured by Yelan 9 June 1993 Information Notice 1993-43, Use of Inappropriate Lubrication Oils in Satety-Related Applications 10 June 1993 Topic Commercial Grade Information Notice 1993-44, Operational Challenges During a Dual-Unit Transient 15 June 1993 Topic Shift Technical Advisor Information Notice 1993-45, Degradation of Shutdown Cooling System Performance 16 June 1993 Topic Local Leak Rate Testing Information Notice 1993-46, Potential Problem with Westinghouse Rod Control System and Inadvertent Withdrawal of Single Rod Control Cluster Assembly 10 June 1993 Information Notice 1993-47, Unrecognized Loss of Control Room Annunciators 18 June 1993 Information Notice 1993-48, Failure of Turbine-Driven Main Feedwater Pump to Trip Because of Contaminated Oil 6 July 1993 Topic Water hammer Information Notice 1993-49, Improper Integration of Software Into Operating Practices 8 July 1993 ... further results
