Information Notice 1993-47, Unrecognized Loss of Control Room Annunciators

Unrecognized Loss of Control Room Annunciators

ML031070477
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, Three Mile Island, 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, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant
Issue date:	06/18/1993
From:	Grimes B Office of Nuclear Reactor Regulation
To:
References
IN-93-047, NUDOCS 9306150062
Download: ML031070477 (8)

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR REACTOR REGULATION

WASHINGTON, D.C. 20555 June 18, 1993 NRC INFORMATION NOTICE 93-47: UNRECOGNIZED LOSS OF CONTROL

ROOM ANNUNCIATORS

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 alert addressees to the potential problem of unrecognized loss of

control room annunciators. 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.

Description of Circumstances

Callaway

On October 16, 1992, while the Callaway Plant was operating at 100 percent

power, approximately 75 annunciators on the main control board illuminated.

After verifying that the annunciators were not valid, the shift supervisor

(SS) notified the plant manager and the engineering duty officer of the

condition and requested instrumentation and control (I&C) technicians to begin

repairs. The I&C technicians found that one of four field power supplies for

the annunciators had failed. The failed power supply was replaced and the

annunciators appeared to return to normal. Two minutes later, while removing

jumper cables installed during the replacement, an electrical short occurred.

In the control. room, 371 of the 463 main control board annunciators

illuminated and remained lit. The I&C technicians inspected the power

supplies and determined that the output fuses for all four field power

supplies had blown. The blown fuses resulted in the loss of all main control

board annunciators. This was not recognized by the plant staff.

Callaway procedure EIP-ZZ-00101, "Classification of Emergencies," describes

those conditions which constitute entry into established emergency action

levels (EALs). The procedure states that, for an initiating condition of

"Most or All Alarms (Annunciators) Lost," the proper emergency classification

is an Alert.

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IN 93-47 June 18, 1993 Approximately one hour after the loss of all annunciators, the blown

fuses were replaced and power was restored to the annunciator system. output

personnel verified that power was available to the annunciators by depressing Plant

test switches in the control room. However, this did not test the annunciator

logic circuitry and, as a result, the operating crew was unaware that

164 annunciators with re-flash capability were completely inoperable.

Apparently, the short that blew the output fuses in the field power supplies

also blew fuses in eight annunciator logic power supplies. Later, while

investigating problems with the annunciators, the I&C engineer found

and

replaced the blown fuses in the eight logic power supplies and an appropriate

test was performed. However, there was not an approved procedure for

test nor was it properly documented. By 7:37 p.m. on October 17 the this

control board annunciators had been restored to fully operable status.main

Because the SS failed to recognize that all of the main control board

annunciators were inoperable after the four field power supply output

fuses

had blown, an Alert was not declared on October 17, 1992. On October

licensee determined that an Alert should have been declared and notified 19, the

and local authorities and the NRC of the event. State

Inspection of this event by an NRC Augmented Inspection Team (AIT) found

following weaknesses: (1) insufficient knowledge of the annunciator the

system by

the plant staff, (2) poor communications and inadequate teamwork, (3)

a questioning attitude, and (4) inadequate work performance. Contributing lack of

the insufficient- knawledge--of-the--annuncl-ator- system wa-rthbefattir to

an off-normal operating procedure or other procedure that addressed e6td-Vhave

annunciators. loss of

Salem Unit 2

On December 13, 1992, control room operators at Salem Unit 2 Nuclear

discovered that the overhead annunciators had been inoperable for about Station

90 minutes. The inoperable condition was detected when an alarm printer

printed a change in alarm status which was not reflected by the overhead

annunciators. The operators reset the annunciator system and restored

operable status within two minutes. Subsequent inspection of the event it to

NRC AIT identified several weaknesses that contributed to the problem. by an

operators were not adequately trained to verify proper operation of The

installed micro-processor based annunciator system. The new system a recently

designed with annunciation as a priority task and therefore it did not was not

indicate a critical mispositioned switch. Attempts by the operators

files, despite a procedure caution, contributed to locking up the system. to enter

plant staff delayed in notifying plant management and the NRC. The The

did not have a procedure to deal with the loss of annunciators. The licensee

concluded that the overall knowledge of the system was inappropriate AIT

system that, if lost, required the declaration of an Alert. for a

IN 93-47 June 18, 1993 Discussion

Although plant annunciators are not considered safety

related, they are

important for the safe operation of a nuclear power plant.

unrecognized loss of annunciators may increase the difficultyFurther, an

problems in plant operations and equipment. In order of diagnosing

for plant operators to

recognize and respond properly to a loss of annunciators, have clear procedures, appropriate training, and effective it is important to

between operators and plant support personnel. For the communications

above, an off-normal operating procedure that clearly events described

would have significantly aided the operators to diagnosestated required actions

problem, take necessary response actions, and make requiredthe extent of the

notifications.

Loss of annunciator events were covered by the emergency

procedures of both licensees, premised upon guidance of classification

Appendix 1 of

NUREG-0654/FEMA-REP-1, "Criteria for Preparation and Evaluation

Radiological Emergency Response Plans and Preparedness of.

Power Plants," (November 1980). The NRC recently issued in Support of Nucleae

Revision

Regulatory Guide 1.101, "Emergency Planning and Preparedness 3 to

Reactors" (August 1992). That revision endorsed NUMARC/NESP-007,for Nuclear Power

"Methodology for Development of Emergency Action Levels," Revision 2, (January

an acceptable alternative. With respect to loss of annunciators, 1992), as

NUMARC/NESP-007 guidance provides an alternative delineation the

declaring an Unusual-Event, Alert or-Site Area Emergency. of thresholds for

This information notice requires no specific action or

written response. If

you have any questions about the information in this notice, one of the technical contacts listed below or the appropriate please contact

Nuclear Reactor Regulation (NRR) project manager. Office of

Brian K. Grimes, Director

Division of Operating Reactor Support

Office of Nuclear Reactor Regulation

Technical contacts: Bruce L. Bartlett, RIII

(314) 676-3181 Rolf A. Westberg, RIII

(708) 790-5776 Scott A. Boynton, NRR

(301) 504-2926 Attachment:

List of Recently Issued NRC Information Notices

It ' Attachment

J. s t IN 93-47 June 18, 1993 Page I of 1 LIST OF RECENTLY ISSUED

NRC IHFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

93-46 Potential Problem with 6/10/93 All holders of OLs or CPs

Westinghouse Rod Control for Westinghouse (W)-

System and Inadvertent designed nuclear power

Withdrawal of A Single reactors.

Rod Control Cluster Assembly

93-45 Degradation of Shutdown 06/16/93 All holders of OLs or CPs

Cooling System Performance for nuclear power reactors.

93-44 Operational Challenges 06/15/93 All holders of OLs or CPs

During A Dual-Unit for nuclear power reactors.

Transient

93-43 Use of Inappropriate 06/10/93 All holders of OLs or CPs

Lubrication Oils In for nuclear power reactors.

Safety-Related Applications

93-42 Failure of Anti-Rotation 06/09/93 All holders of OLs or CPs

Keys in Motor-Operated for nuclear power reactors.

Valves Manufactured by

Velan

93-41 One Hour Fire Endurance 05/28/93 All holders of OLs or CPs

Test Results for Thermal for nuclear power reactors.

Ceramics Kaowool, 3N

Company FS-195 and

3M Company Interam E-50 2 Barrier Systems 2

93-40 Fire Endurance Test 05/26/93 All holders of OLs or CPs

Results for Thermal for nuclear power reactors. 0

0

Ceramics FP-60 Fire

Barrier Material (n IN0)

05/25/93 All holders of OLs or CPs (n0 too

93-39 Radiation Beams from

Power Reactor Biolog- for nuclear power reactors.

ical Shields _ U,

0o

-o

oL - Operating License 'hi

CP - Construction Permit

49a.

z

z

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

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: Bruce L. Bartlett, Region III

(314) 676-3181 Rolf A. Westberg, Region III

(708) 790-5776 Scott A. Boynton, NRR

(301) 504-2926 Attachment: List of Recently Issued NRC Information Notices

• SEE PREVIOUS CONCURRENCE

• RPB:ADM *OGCB:DORS:NRR C/OGCB:DORS:NRR D/DORS/NRR

RSanders JBirmingham GHMarcusgil BKGrimes /

03/17/93 05/06/93 05/.2'7/93 05/ /93 tW

• R/RIII *RIII *PEPB:DRSS:NRR *OEAB:DORS:NRR

BBartlett RWestberg SABoynton TKoshy

04/21/93 04/22/93 05/04/93 05/05/93 DOCUMENT NAME: ANNUNCEB.JLB

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

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: Bruce L. Bartlett, Region III

(314) 676-3181 Rolf A. Westberg, Region III

(708) 790-5776 Scott A. Boynton, NRR

,,n1n % CAA _nnn

Lt Rcl I d NUR-CT i N e

Attachment: List of Recently Issued NRC Information Notices PA A /4 4)

• RPB:ADM OGCB:DORS:NRR C/OGCB:DORS:NRR D/DORS/NRR

RSanders JBirmingham. GHMarcus BKGrimes

03/17/93 05/ a /93 /: 05/ /93 05/ /93

• R/RIII RI IJ})M' P 4NRR: OEAB:DO :NRR

BBartlett RWestbeVg TKoshydi

04/21/93 05/& /93 05/5 /9 DOCUMENT NAME: ANNUNCE8.JLB

..... .....I

3 have clear procedures, appropriate training, and effective communications

between operators and plant support personnel. For the events described

above, an off-normal operating procedure that clearly stated required actions

would have significantly aided the operators to diagnose the extent of the

problem, take necessary response actions, and make required notifications.

The NRC recently issued Revision 3 to Regulatory Guide 1.101, "Emergency

Planning and Preparedness for Nuclear Power Reactors." That revision

endorsed NUMARC/NESP-007, Revision 2, "Methodology for Development of

Emergency Action Levels," as an acceptable alternative to the method described

in Appendix 1 of NUREG-0654/FEMA REP-1, "Criteria for Preparation and

Evaluation of Radiological Emergency Response Plans and Preparedness in

Support of Nuclear Power Plants." NUMARC/NESP-007 provides guidance that more

clearly delineates the thresholds for declaration of an Unusual Event, Alert

and Site Area Emergency.

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: Bruce L. Bartlett, Region III

(314) 676-3181 Rolf A. Westberg, Region III

(708) 790-5776 Scott A. Boynton, NRR

(301) 504-2926 Attachment: List of Recently Issued NRC Information Notices

• RPB:ADM OGCB:DORS:NRR C/OGCB:DORS:NRR D/DORS/NRR

RSanders JBirmingham GHMarcus BKGrimes

03/17/93 04/ /93 04/ /93 04/ /93

• R/RI II /4 RlIl m PEPB:DRSS:NRR OEAB:DORS:NRR

BBartlett RWest erg SABoynton TKoshy

04/21/93 04/XR./93 04/ /93 04/ /93 DOCUMENT NAME: ANNUNCE8.JLB

IN 93-47

-~ ~ June 18, 1993 Discussion

Although plant annunciators are not considered safety related, they are

important for the safe operation of a nuclear power plant. Further, an

unrecognized loss of annunciators may increase the difficulty of diagnosing

problems in plant operations and equipment. In order for plant operators to

recognize and respond properly to a loss of annunciators, it is important to

have clear procedures, appropriate training, and effective communications

between operators and plant support personnel. For the events described

above, an off-normal operating procedure that clearly stated required actions

would have significantly aided the operators to diagnose the extent of the

problem, take necessary response actions, and make required notifications.

Loss of annunciator events were covered by the emergency classification

procedures of both licensees, premised upon guidance of Appendix 1 of

NUREG-0654/FEMA-REP-1, "Criteria for Preparation and Evaluation of

Radiological Emergency Response Plans and Preparedness in Support of Nuclear

Power Plants," (November 1980). The NRC recently issued Revision 3 to

Regulatory Guide 1.101, "Emergency Planning and Preparedness for Nuclear Power

Reactors" (August 1992). That revision endorsed NUMARC/NESP-007, Revision 2,

"Methodology for Development of Emergency Action Levels," (January 1992), as

an acceptable alternative. With respect to loss of annunciators, the

NUMARC/NESP-007 guidance provides an alternative delineation of thresholds for

declaring an Unusual Event, Alert or Site Area Emergency.

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 signed by

MI-(. 'rimes, Director

Division of Operating Reactor Support

Office of Nuclear Reactor Regulation

Technical contacts: Bruce L. Bartlett, RIII

(314) 676-3181 Rolf A. Westberg, RIII

(708) 790-5776 Scott A. Boynton, NRR

(301) 504-2926 Attachment:

List of Recently Issued NRC Information Notices

• SEE PREVIOUS CONCURRENCE

• RPB:ADM *OGCB:DORS:NRR *C/OGCB:DORS:NRR

RSanders JBirmingham GHMarcus mes

03/17/93 05/06/93 05/27/93 05,/l 93

• R/RIII *RIII *PEPB:DRSS:NRR *OEAB:DORS:NRR

BBartlett RWestberg SABoynton TKoshy

04/21/93 04/22/93 05/04/93 05/05/93 DOCUMENT NAME: 93-47.IN