Text

Rept on Reactor Trip/Engineered Sys of 790423.W/NRC Routing Slip
	ML19220C505
Person / Time
Site:	Crane
Issue date:	04/23/1978
From:	Seelinger J; METROPOLITAN EDISON CO.
To:	;
Shared Package
ML19220C506	List: ML19220C505;
References
	NUDOCS 7905110079
	Download: ML19220C505 (49)
	v • d • e

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) ~.\\ L I i. s. h / j 3. r.' u M ETR C PC Li'I AN EDISCN COM?ANY

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...c 2.,. o., 2,m.m, DI Lciaar 3:2:i:n , g a.. e,. _, q, -..,.,-.,, / a-...,.,-.,t. ..,,,,,,, 2 L::: u.n r e... c. n .s.r t..v.. :.. a, a e g.:: una ,2 y,, 1 -, s Ta "R. G. P. MILLER Encicsure: Subject Re;cr: 1. The finalized re;cr: i s for,arded. / 4* y &b. : y -? 3) J. L. Eeelinger / L*ni : Su;erintandent' Tecnnical Su:::ce: JLS:;is @N.r 3 0Ylin - = 3m-c:: J. J. Bart n G. R. Hi t:: ff L. Seers R. W. Kaat n R. W. Sensel R. M. K1 inga. man

3. G. 5.mith M. L. Sensan G. A. Xander R. J. Tccie T. G. 3r::ught:n L. C. Lanese G. J. Troffer J. A. Er= er L. L. Lawyer A.

Tsaggaris J. J. Chwastyk S. Levin E. G. Wallace R. C. Cutter T. A. "aciey

3.. W. Zechan

'4. J. Fel s

3. A. Menier

'a. H. Zewe J. R. Ficyd J. P. O'Hanien J. G. Frit:en W. T. Gunn W. E. ?ct:s J. P. ":cre J. G. Her:ein L. C. :.cgers R. W. Heward M. J. Rcss J. F. Hilbisa W. F. Sc.rauss 7' ') 1 1 LO L1 1 7905110c 79 . 6.., -, r - h .....,...,,. 1 ..:.....,....e..

i. c

O ,w e e .F 1 *. Rx Trip /E5 Incider.: 4/23/73 e LU Ll-

e Table of C:ntents rige I Synopsis of Event 2 II Sequence of Events A III Canclusions 10 I'I Rec mmendati:ns/ Action *: ems la A::endices A. Sez;hs 18 3. Chemistry Parameters after Even 25 C. Pressurizer Level Calculatiens 29 0. Sup;crting 3 & 4 Analyses 31 4 xcugn cata -0 m e . = (1) Fest."emc ry. Trip Revi ew 41 (2) C::: uter Alarm Frintout 46 (3) Reectimeter :eicg Ca:a 57 (4) ICS Transient Res;cnse Traces 34 c t }l) ') i c) u< c 1

4 ,? e t o lT f I I 4 p l Rx Trip /.E3 Inciden $ /) e i h I I e i i, [ d-20 L'

_ _ _. ~. Syne; sis of Event

act:r tr ; wnile at i

At 1551:23 on 4/23/73 24I Uni-2 ex;erienced 1 .' C % r,. 2 c..' ~ ~.w 2 - ?. ". s.. a..oic.c-..i.'<=.. '. F. u, +, e' r. '. n c, a. ". a '. t.... r. i. a. . ~ e react:r :-i::ed because RF5 charnel C was already in :ne tri;;ed s:2:a .e 'F.'/. .i s rac u i re.d. b.y Te.c..'.n. i c.' l

e. r.r.. e. <.,.3. n. a..i..i. l. I

+..e

.a

...e i n o..,..r.e.m i l i.- a. o -4 When the reacter tri;;ed the turbine tri;;ed causing a very rapid :ressure increase in the 3 075G and a slign:ly sl:wer pressure increase in the A 0753. Fcur of six main staan relief valves lifted on the 3 OT5G ar.d very rapidly blew pressure down in the 3 stain generat:r. Cne main staam calief valve lif ted On the A OT53, and it also caused a ra:id pres:ure bicwdown but abcut 40 seconds delayed from the 3 0753. The 3 Tur:ine Sypass vaive received a signal to go full c;en but aimest f eradiately received a signal Oc go full closed due to the rapid :ressure decrease in the 3 Ci:u. ine A Turbine Sy; ass valve recaived 'a signal to c:en at the ;re:er pressure but the signal :: cpen the bypass valve was lower in ragnituce than it shculd have been. The c:erators :ck the pre;er irredia*e acticn in manually.'utting back feecwater demand, shutting MUV3753 (the le:d:wn isolaticn valve}, starting a sec:nd makeup ;umo, and caening the nign pressure inf ection valvas on the side of :ne : era ing makeuc ;um;s. The a: erat:r failed to initially recognize na the feed ;.mp as in manual and did not run :ne feed pump 5:eed back until a;;roximataly I minuta and 20 sec:nds had ela: sed. Earlier acticn here wculd have mitigated the causualty but due to icw initial feedwater ficw and the effec: an feedwater after the 0; era:Or ::ck this action, the mitiga-ing effect should prc: ably no: have prevented going dry or the 5FAS actuation. The 4 3 side main statm safety valves and 1 A side main staam saf aty valve failed to pro:erly reseat. The safety valves en the 3 side started to reseat jus :ricr : 2 minutas into tne event with the remainder of tne 3 safety valves anc A safety valve resaa:ing a'mcs: 1 minutas into the cvent. The steam genera:Or pres:ures anen the safe y va!ves reseated were between 550 - SCO psig. The ICS c:n:rol of the fescwater valves had not ye been tuned 2: the ti e of the event. Integral vice :r::crtional c:ntrol was the ::minating signal en the feecwa ar valves and al:ncugn :ne valves res:encec in :ne

re: er directicn, tney res; nce: mucn sl:wer nan :ne traci:icnally ex:ected Thus wi a feedwater valves sicwly going shu:, ra:idiy cacreasing res;cnse.

steam generat:r pressure, and a ::nstant feed pum; s;eed ::c mucn 4atar was fed into the staam ger. erat:rs. ine sare:y valves failing :: reseat cou; led wi n :varfeeding caused a r30i de:ressuri:aticn and ::cidewn of Me reac::r ::ciant sys:an. The :C2 went from 533F :J 464F in ? minu:as. The RCS snrinkage ' :m :ne c::ia:wn e i,.w .., :, s :.,. = s. .,. <,. 3.,.,,-,.,...,.. x :.. ~,., s y. i.. . s. .ra.e ..r. m.,n.n c.,... e s. .2. ...., s... r 1..,

a. n,

+, ...T..,,. . u.,. n..,,..r .,e ..a. r,..1 ~ ..a. i. 1..J.,

C3, SFAS safety injec-icn ec:urred 1::roxima:eiy one minuta af:ar :ne react:r

..q,. w . 2 ') 0 2k) c.

Fres:uri:er level was res : rec 2 -inutes int: the even: as a resui: of -'.","..'.".*.,'."~d .a. J f ' ".. a. 2 '..'. e -

n..$ l "v.

' n.i A.'.. ' c ri, '" e A "iJr '.'. .2 e 3 :. 2..y. s .f .a i main steam reliefs going shut. Feecwa er lat:n :::;rred 21/2 minutas into the event and terninated feedwatar ficw. Feedwd:ar laten,as the key ev>.n in :Lc::s:- fully t:rminating the transient. t The event caused viciaticns and Technical I;ecifica:i:n acti:n statemen entries in that: (1) RCS C:aldcwn limit of 1:CF in any 1 hour <as exceeded (actual 12aF) - T.S.3.1.9.1. (2) Fressurizer c cid wn limit of ICCF in any 1 hcur was exceeded (actual 126F) -T.S. 3.4. 9.2. (3) Fressurizer was emo ied and c:nsecuently was bel w the Technical Specification limits - T.'S. 2.4.4 (1) Tr:nsient chi; ride limit of the :CS was exceeded in that safety injection pumps sccium hydr:xide into the RCS and there is inherent cnicride c;ntaminaticn in the sedium h droxide. Highes: level saen was 2;;m - 6. 5..,. a.7. The folicwing limits and precautiens were viciated: (1) 31W fuel pin c:=pression c:cidewn curve. positive suction..ead ror the reactor c:claa: pum:s was not u ine ne: violated. Centrol rod drives limitaticns were not viciated. (i shcu'd be notec safety r:ds were c cked af ter this event and based upon ;o;<ible gas in the CED's this s'culd not have been done). Calculaticn-performed irredia aiy after :ne even; and su:secuent chemistry analys :s shcwed tha :he c:re remainec c:vered at all times. Althcucn the bubble left the pressurizer and went into One or both hot legs, the hot leg with -he bubble, if :nly one had it, was a: least still filled with water naif way u: the heign of tne leg. If 50 n not legs had a bu:ble then One legs accid have :een filled 3/1 of the aay u: :ne legs. Zuring recovery and wnile :eginning :s ::cie:wn 15 minu:as af:ar :ne event, a sec:nd SFa5 safety injec-icn accurred. This :ccurred cue to a mixma::n between censale :ressure indica:icn and nat -as seen by the E.S. bists:Tes. Tne c;erator was reading 1720 psig On aide range pressure instrumentation wcen :ne sec:nd SFAS safety injecti:n Oc:urred a: 1620 ;sig. ine d.-S signal was immeciataly by:assec and c:cid:wn ;r:ceeded nc-rally fr:m :na: :oint. ..a.

I i Sequence of Events e (E.<planati:n and Correlati n to Grapns included) f. c L. V -4

l f . n.. a.. i,, i.

e. r :.. ;.,. s a

l Tita Zer 15:51:23 i React:r F wer 30% .~eactor c:ciant pumps l A,13, 23 running ..,r- .iav =c. Pressuri:er heater: in aut::atic -ree., water.,:cw: 0 A .3 x 10 lbs/hr. 0 3 1.7 x 10 lbs/hr.

eactor Cecian: Pressure 2217 ;sig

.YW-235 a ICS Statiens: Ciamond in manual 3ailey ~eactor master in manual ree,. water ;um; running and in manual .a g o.o. r.W a

a r,.. r 3 c-... r a.d.

r. A and 3 main ar.d s'tartup feedwater valves in Au A and 3 feedwater demand staticns in anual 5:aam genera: r/~eactor da.macc in a t: u Turtine in Aut: A and 3 turbine bypass valves in Au:: A 5/G controlling en icw level l'ait and A feecwatar demand anually se: at O. ) ) '} E 'L '

7 3:C0 Ex trip i Caused by noise s;i'<e en ?4I3 (C R?S cabine -as already tri;;ed cue to incoeracility cf ti!7). 7 0:01 Turbine generat:r trip. T 0:05 3 S/G STU limit due to increasing S/3 pressure (;raen A pt 1). I T 0:10 3 S/G increased mcmentarily to 1C40 psig. (;ra;n 3 ?t 1) "$R13, 23, 43 and 53 lif ted 3 FW ficw d1 creased :o 0 due :: rapidly increasing 3 S/G pressure (graph A pt 2) 3 turbine by pass valve opened mcmentarily ard then closed. T 0:12 3 S/3 STU limit cleared and c; erat:r ran F4 demand statica 3

0.

(A FW demand station was already at 0 as ne A GTSG was on the icw level limits). 3 FW rapicl/ increased due to rapidly decreasing S/G pressure. (;raph A p: 3) 3 FW valves started to cicse" Currently the FW valves have not been tuned and integral vice pec;articnal ::n r:1 is d:minating. Ccnsequently tne FW valves res;cnded very sicwly. T 0:13 A S/G pressure rose to 1025 psig and remained there for 27 seconds (grapn A p: 4) Cue to high S/G ;ressure A FW ficw dre;;ed cff scale icw. (gra;h A ;; 3) T 0:13 Fressuri:er level at 130" and rapidly decreasing (gra;n D ;; 5) u.. a..... v,/, < o- .3-e.... i 7 0:23 A S/3 beicw icw level limits and SU W valve starts :: 0:en (gra;n A p: 7) 7 0:20 3 S/G STU limited ehicn is dcminating the FW demand signal, newever be:n signals are telling the F4 valves :: ;; snu and the 3 FW valves are driving shu: (;ra;h A ;; 3) A turnine by pass valve went shu (gra:n a :: 9) ?,, '))G 3-o ,,m m M

N**

G -N

i

0. 3 m..r.a. w.P,,.,,

i Cpened YUV15A/3 7 0: 27 ?res:uri:er heatars trip;ed 1: 30" in pres;urizer (gra:n D pt 10) T 0: 23 A FW ficw back en scale and rapidly increasir.g due :: decreasing S/G pressure and SU FW v.tive :pening (;ra:n A ;; 11) A S/G level increasing due : A tur ine by pass valve shu::ing and decreasing steam pressure all; wing fice : get in S/G (graph A pt 12) T 1:CS Pressuri:er level off scale (graph C p 13) T 1:11 Safety infection A and 3 side due :: icw pressure. 1630 psig (gra n 0 p: 14) C; erat:r verified MUPlA and 1C an, CHV 5A and 3 0;ening, ChV 2A anc 3 cpening. I 1: 12 A S/U FW valve going shut due := level being abcve the icw level limits and the FW demand signal being a 0. (gra;n A p: 15) A FW ficw r=maining c:nstar; even thougn $U FW valve going shut becausa of decreasing S/G pressure (graph A pt 16) T 1:17 Safety injecticn bypassed. (gra n 0 p: 17) T 1:20 C: era: r ran FW ;um: s:eec :: minimum. Fw ficw :: 3 S/G started :: dec ease faster. (graph A pt 13) T 1:40 Cicseu CHVSA and 3 (These valves were not yet full 2:en) (gra;n 0 p: 19) HPI flows were a:;reximately: "A 1 2Cgn: 'S i tg;m C 3CCg:a 0 -vgpm 'Ficws icw ;rimarily due ::.MUV 17 and 13 being : pen. T 1:48 3 S/G level increasing. Scme of :ne safety valves On 3 S/G shut. (;ra:h A :- 20) 3 S/G pressure a: 560 :sig. Sasec :n :nis pressure rW la ch should have Oc:urrec socner en 3 S/G (graph A ;; 21). Pressurizer level rest: red :: ne incicating range (;ra:n C ;. 22', ey 'r I L L.' gO 7

l --:10 S. m,S high ;ressure i.jsc icn due to.icw s.t. ;recsure. i i 1, <..y;.g.:....,..,..,......,.,. .. w, z.. e, a........;..~....., s.. bypass valves. Me ~.:uld have ad in alarm : 152C:sig to tell hi.m safety inj+cticn was not bypas:ed. Per ;.;cature he is to bypass safe y injecticn ba:waan 132C:sig ar.d 17CC:sig. -#.:.'l '...e..a.r.'. rs '. di-' 2d ...] in#a.r..4. 1 .w,.:..,. ..,,2... 2 a ns.... pressure on the c:ns:le was 172C;sig. Thus there 4as i discrecancy I between conscle indica:icn and ehat the safety inf acticn bis;acies were seeing. a e.,., bypas:e-. ~ .r.- i T 44: 20 CHVSA and 3 closed. o, 'J

t. -

v

T 2:15 A S/G ?ressucc ~20 psig (gra;n A ;; 23) FW latch on A S/G relative :: the time 7is ;ressure oas raicned a;; eared :: te satisfact:ry. c ..at:n (;ra:n a, pt,c,) a c:,+, . side r4 i u 3 S/G level decreasing. Scme 3 S/G relief valves still :;en (grapn A pt 25). A FW latch (gra;n A p: 26) A S/G level decreasing due :: MSRIA being 0;en (gra;n A p 27) T 2:30 Cperator ::ck manual c:ntrol of A and 3 FW valves and atta.m;ted to apen for short period. Then c;erator attempted :: close for snart period. (This did not have any affect due :: FW lat:h having taken place). RCS tam:erature at 475F. Rate of decredsa sicwed c:nsidera ly (graph E p: 23) Thr : led MUV 16C to 25Cgpm MUV 150 to 25Cg;m (gra;n C ; 29) T 3:00 RCS pressure reached its icwest value of 750 psig bef:re :urr.ing and increasing (gra;n 0 pt 30) St:;;ed MUP1C C;enec MUV 6 and 37 T 3:28 3 S/G level st:;;ed decreasing due to remaining 3 S/G relief valves shut (graph A p: 31). MSRI A shut (' graph A pt 32) T 4:C0 A 1::reximately this time MSV 23 anc 73 aen: snu: fr:m ne previcus 3 side FW latch si--al. T 4: 11 MSV 4A and 7A ci sed fr:m tr; 2vicus A side FW lat:5 signal. T 0: 14 C; erat:r started EFP2A A S/G level started to rise 3 S/G level staye: c:nstant (C; erat:r has no indic2:icn of - /llr./3 valves in :ne c:ntr:1 ream and ne ::: nc: :en :.-lli:

rfar encugn to ge: aater into the 3 $/G (gra;n A ::. 33).

T 3:03 EFP1; secured (;rapn pt. 24). T 22:16 Securec RC? 23. 8 {

j .I C: erat:r a tion c I t s ..... d. ^.. '. *. a 1' *. 3 ..e ]. rrer.i r

c. c.-r..se +.,

re.,r.. r. 4,, 4.3 .r. n. - as..s. .r.. n..3, X. n... I

1.. a m. 4....-

.. e-

2.. N..

.r ..... s a X r 3 n.. v.,.... 3 4 c r. ...s r. i 2. While the :; erat:rs res:cnded c:rrectly :: the react:r tri:, they did not realize :ne casualty they were really dealing with aas a major steam leak (througn ..e relief <alves). i 3. The c:erators during the transien never fully gras;ed :ne damaging effect of feedwater en his situaticn. This is evidenced by the acti:n taken with the emergency feed pump a minutes in*: the even t. 4 C;erator action with feedwater shcws that the c;erator watched the neecles en the Sailey s:sticns instead cf the actual measured , a .r.e...= - s. ' n - =.... c. e r.., ' a r. ".. a..r 4.....~.-e n ~.#. e..h r a .m criti:21 things as FW 51 ck valve :csi-i:n is badly needed. Also af ter.37 la :n, signal indication and reasured paran.aters 4ill i disagree. 5. C; erat:rs, having been trained n :ne IC5 :n the 35W simula :r, with the untuned ICS and sicwly c era:ing fee:watar valves. The slew res;cnse of the feed valves

nile in auto sig.iificantly hindered the ability of the uni: :: c:pe witn the casualty.

6. When the second E.S. occurred the ; erat:r was foll: wing his cocidcwn ;c:cedure and E.S. shculd ro; have had :: have yet been bypassed. 7. Cn the E.S. when the c: erat:r saw inadequate ficw through the MUV15's, he did not reali:e ficw was alsc going in thr;ugn MUV17 and MUV13. i t 2 -ine

erat: rs acti n in res;cnse t One

.d. 1' .;cth c:ses was ice .S. was cuickly %ypasse :: rt n c n:rdi and a very gced. t and the CHV8's were pr:mptly shut :: kee; fr:a u - -ing tne R.C. system. E:uirment ;e #0rmance 1. Excessive blewdcwn by the 5/3 relief valves is :::2ily uncatisfac ry. 2. S/G safety valve pipe liners must be recaired as some did nct remain intact. alve did not a:: ear :: ::en far encegn. 3. The A turbine ' r.. - a r ;.,, nn.i~n,. e a,.., ,,a-a . -.,. r a. s.. -. e e.:.-- 1,.. a.t,- c all by; ass valies s ening and cl: sir.g cnaracteris-ics sneuld :e examinec. n[ L. u 4.0 4 The main and star up feedwater valves need :: te turned as scen as ;cssible :: significantly decrease their rec;cnse times. l c. 7t. e 3 c.. 2 - 4. ,.. r o. c e r a.

a. #. # =. c.. a c-. s r l a..."... c. a. d e.

.... e

c... a. r. < -..

i .o e .a =- 6. F. - =. n i r3" * " e.'.'#. /.2 ' 2.n a*c.'#.=..,> '..n.' =. e.. #.1 "2.,.. a l ' s. ". =

....'. - ' d.

. 3

= avoid inadvar ent.Na and Cl c:ntamina:icn of the ECS.

.. ice re:e:nse er t.u.c _:.-_. s ..u s. '.a .'.e-r. 2 n.'~,. ..'.m..-. a r s.. r .s. tried to f:ad the 3 0753 by " bumping" this valve, but nc -ater inau; a.so neecs to.c cor.fi ad. s _ine valse l. went in. I S. he c nscle wide range pressure indica: Ors must te checked agains: hat the safety injection bistables are seeing. I 9. Why the sequence of events cid not print cut en the c:r..; uter i 1 ,8 rust be resolved. I 10. The time lag in selected parameters such as flux in the ccm: uter me:Ory trip review must be resclved. 11. .Nu c! = = - i n e... ".r_a n *..'. 4..n e - i ' = s..a s. 'e

..u o d.

2...d . r. a. r...= d.. .1.' '/ <s ^ a.'." i l i.'j. ..u s ". e .-a. s.r o.d. .r i P -a. c e d.".. a. s 1. .vore s:ecific guidance in scre areas c:uld have keyed the l cpera:Or into such things as running feed datar pump speed dcwn-- see rec:mmendations. .hilosc:hy 1. We must understand each specific evciutien and the res: likely c:nsequences or eculprent rai.ture or malr.unc ;cn. We mus: a;;rcacn evolutions w1:n tne ques-icn, "hcw wculd

res;cnd if

a..n..- s. -

a m ,.e rust st p and regrcup when scre:hing is margina..i y wcrting cr 2. a marginally underst:cd. Acverse affects can be accitive. 1 "n "< ed... a. s w" e$.v,,2 r. i 'i.:.". ;' "..q i... d. ~ a.d.

...7.. 1 : ".

v-a.. ".".a. Iu-e..e d v u a o <. e.,..s. 2..s r 2c-iss.n. .2,.ee.

..v ers..r.-. r wr.=a. "i.w...~,

."^wn i . ~.. w.. ... = i.v. = d. 2..'. .'-'. =. ~~e

.*. d.'g w a..c c^ndenea..=

t~..~

e. u' '.. #. w n s.. '. '. ~. a.r.

to a r. 00cugn; at the time *: he adequately uncerst:cc. Eeanaly:ing "Ne wi:n hinesign: frcm the Acril 23 trip snews the same excessive cl: c cccurred in both steam generators. Had icss of feed not been t"e i-event, E.S. initiaticn c:uld have cc:urred en the earlier tri?. Thu wnen investigating a trip cr transient each parameter. us: no: :e ar with " tunnel vision," but rather must te 1:cked at inca:encently an: n.w.e,.-. d. v a. l.v

. r r. - =..

e r #.. r-... - =.. r c0 I .e 14 i t i. -=

4. The main and startu feedwatar valves need to be turned as scen as ;cssible to significantly decrease

heir re ; nse times.

I 5. The actuaticn pressure of feecwatar laten needs to be checked. 6. C;ening the CHV3's en a safety injecticn si;nal mus: te changed Oc avoid inadverten: "a and Ci c:n:amina:icn of the F.C5. a 7, .. ice res;:nse er Lu.e - ..us. '.e .".e.. in

..'.a.

'.e e-'..^r v = .,y u s.. r-4. "3 .*.is valve, 'u ..c aa*.ar +.4.,3., e.so.d .w..... a g6.ge-w .s went in. The valve lineus also needs to be confirmed. t 8. The c:nscle aide ranc.e ressure indica crs must be checked e against what the safety injecticn bistables are seeing. 9. Why the sequence of events did not print cut en the cc:puter s' ,I must be resolved. 10. The time lag in selected ;arameters such as flux in the c::: uter mercry trip rev'aw cust.e res:lved. ~.s...n.~(< ..u s- " a.

. ~ u.. d a.. ". ".... a. e...= s..

.'V. 7 ...." ' s.. e 11. ~~ Js. ' t . 3 ,.r,.r., 1 1...f. i l Precedurt-I 1. More s -' "- te c ? in sste areas c:uld have keyed the i Operater ,ch things as running feed water pump speed dcwn-- see rec: r sc.cns. rhllo!C*nV l 1. We rust understand each s;ecific evolu:icn and the rest likely c:nsecuences of ecuipment f ailure or malfunc:icn. We must ap:r aca evoluticns witn the cuesti:n, " hew would I res;cnc if i ,. 2 -. e r. a.s. 4 2. We must st p and regr:up wnen scmething is marginally wcrking cr marginally underst:cd. Acverse affects can be accitive. ':"..u~a.r. "u=. '-e.-. 1 Cn Wed...a.s"'v,. ril '6.O..". =. ". n...

d. -. e A.

4 i. a ..= c - 4. c =..q '... ' ".. - =.. '. v - e..s . r =..-.. r 4 r. s.. ". I. w i.. ..wn .= ^ #.

. =. a. d.w a. = ".

c r~ e n <. a = ur.. c s " e. 4.

r. s...' 4.,. a. r.

. a.. ". w =. 2

2.. a.v - 2.

~ r ..... -.... ~ =. .. =..a n a 'i.v. "... 3... e..-

" ru c. n. a

..*.a. . 4...e .o '. e.=. =.e ".'. = l.v

J n d.e r. s. c..

.. ~ y witn hincsight from the A;ril 23 trip sncws :ne same excessive :10-c c c." r. a.s. i n 'c.5 s.=.=.'.. c, a... a r..s.. r s.

u. 2.d 'as v~#.

'. =. a. d..a.c.. a. o. n..". e '. - . a = v a.a..,.. S. '. n i. i.> *.d. e n v-.'J '6. ".. = v a. c -". -. =. d.. n...a" =. = r l i. e r. .. 4. r'. ~ ~.. d .a. i when investicating a trip cr transien* eaC3 parame ar mus Oc* te ar w j... " *... n n o. ] y i e. j C F., * *u *. "4'. ".. e * ", ~" * '. e 'i.. k = '..' '. #. d = ", =... L'.2.. 'l.v . = -. a i chi.. a. c.. 4..9. ] y

e.. p

.p a.r a. t. r r. r".2. - s.. p... 9 -) l " r L. -] / L. 1 - i -e

Traininc 1.

is no: likely tha: ; erat:r training n the simulat:r w:uld 3-

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he steam leak.

2. A talk thougn with "what ifs" might have significantly helped with recogni icn of the steam leak /cverfaed pr:clem. 3. See recommenda:icns. Other 1. More indicatier, of critical Opera:cr items in the c:ntrol racc is needed: FW block valve ;csition indica:icn E.: valve positicn incication Turcine bypass valve ;csiticn indica:icn atmospheric relief valve ;csiticn indica icn Main steam relief valve positicn indica:icn 2. The number of inc;erable alarms in c:ntrol recm needs :: be reduced to a manageable level. 3. Mcre alarm ackncwiedgement ca: ability in c:ntrei recm is needed. f . I1 qO* \\') o ;- v- = b

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_L$ v. 1. Scive relief valve discharge piping ex;2nsion join pr: lems - 3FUSC 7:11e/ Levin prior :: startup. E. C:rrect nuclear in truR.eatati0n Or:ble.:s NI7 inocerability, NI3 ncise s:ikes, NIS possible crim;ed cacie, nit ercing preciem - Stummer - price to startup. 3. Get CHVS c;en signal injectica - G;USC 3rcughten/Tcole - prior to startup. A. Scive relief valve bicwdcwn ;rcolems - G;USC Tecle - prior to criticality. 5. Actuation pressure of feedwater latch needs to be checked fcr prcper response - 3rtmmer - price :: s ta rtup. 6. Conscle pressure indicat:rs cus; be checked agains: 5FAS safety injec-ica bistable pressures - 3 rummer - price :: startup. 7. The res; case of the EFVil3 valve must be checked. The valve lineuo f:r emergency feed rust also be c:nfirmed :: be pr ;er - 3 rummer - ;rior to s ta rtu p. 3. Turbine bypass valves pre;er c;ening and tuning must be performed - GFUSC Tcole/ - during heatup and ;cwer escalation testing. 9. The main and star u feedwater regulating valve c:ntr:1 reeds :: be tuned C n.e iacie - during ;cwer escalaticn testing. 5 r.c 10. C: ; uter problems with the sequence of events and memory trip review need

be resclved - Fels - pricr to startup.

11. C n r:1 reca ;csiti:n indica-icn is r.eeded for the felicwing valves: a) iurbine ypass valves s b) Pain and startu: feedwater bicck valves c) Emergency feed c:ntrol valve d) Atmcscheric relief valves GPUSC - Tccle - de armin2 G?U$C ;csition n making the ciant cnanges .2 c.--.. w i 4. e r... =. c e

w.. =.. - a. e.

.v.$.v -o.c,.. 'a r a d w ,,c. -r: vide s me indica:1:n Or main steam retier valve ;csiticn. x temocrary i microchene fr:m One vicinity cf the valves :: :ne con rel r:ca has been suggestec. In this way the 0: era: r c:uld at least ce e:t inde:encen cf an=lyzing :nscle indica icn that the relief valves are :cen. 3FUSC - T:cle - price :: s artu:. 13. Change main feecwa:er bicck valve signal :: ::en f := C% : 3C5 : en :n the startu fascwa ar regulating valve. This 4111 be ::nsis en: wi n Unit 1 inc sneuid reduce One :cwer level a wnich bicck valve incucec flow escillaticns cc:ur. 3FU$C - Tcole - ;ricr startu. q )o e L. G () 1 L

12 Prior :: again achieving 2C" ;cwer determine 00:irum m.inimum fee:watar pum; speed so unit can go througn the pericd of ficw cscillati:n wi:n feecuater pump in au:3. G;USC - T cle - during ;c..ar escalatica testing.

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..i 1. Revise precedures to insure: a) More specific guidance is included with res; c.t to ICS staticns being in hand en a react:r' trip and other major casualties. Flag to the c; erat:r which staticns :: specifically lack for :: run back - Erummer, May 10. b) Include limit and precautien in c:cidewn and CRD c;erating precedure to insure safety rods are not 'c:cked" until a depressuri:2:icn situation has been analyzed. Sensel - May 10. c) riag :: the ccerator en safety injecticn to not en,ty monitor hign .;ressure injecticn ficws, but a:sc ficw througn MU/17 and vuVla. Flag hcw to pre;erly throttle ficw in this situa-icn - Mackey - May 10. d) Revise startup precedure to ;revide tne c;erator with 5:ecific guidance as to Ecw to drive the piant thr:ugn the l'" - 22". feedwater bicck valve osciliation pr:blem. Use the collective meth:dclogy of the shift supervisors and change precedure so that this is dcne in a uniferm fashicn frca shift to shift - Floyd - May 10. e) Include in limits in precauticns for the ICS ;recedure a statement to minimi:e the use of ICS stations in hand. Brummer - May 10. .:u n. e.c- - "nY _ve 1. We mus: sicw down and proceed forward deliberately and c:rrectly. Senice station management mus: ::nvey :nis ;nilesc;h; :: shif: :ersonnel - 3. Miller /R.J. Tecle prior :: startu. 2. We must analy:e each unkncwn bjectively and thercughly and res:end : the conclusiens reached ni n g:cc engineering 'ucgement. G.P. Miller / J.L. Seelinger - en ;;ing. ...,.J...,-...u 1. Review this transient and all other trips and transients to date with all c;erating shifts. Such reviews shcule be c:nducted <nen feasible c.1..-a l s

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s i. ". =. '.. n. i n #.,. r.. - f.- a s F1cyd - May 10. 2. Write supervisci of c:erations acc 4nich ciscusses ;re-evc'uti:n brief' gs, the neec for these br efings :: review the Ics: ;r :acie ex ectac abncrmalities, -he need for tnese triefings :: be ::nc.ctec, ur.enever 'n. ~# . ". a. c. n.. 'i e..

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~.---- TEAINING (C:nt'd) 3. Ceveico standard fermat for hcw a trip /rajer transient gets raviewed in both units 1 and 2 with each 0;erating saift. Ficyc/F ss - May 10. 4 CR0 training must stress and teach the c: erat:r to watch and m: nit:r measured indications vice 5ailey ICS signals. ZecPman - icng tarm. 5. Simula:Or training is a definite ascet in helping the c; erat:r rec:gnize and respond to this type of incident. a) Reevaluate sending the single unit licensed operat:rs to the simulator each year vice every other year. Zechman/Tsaggaris - Icng term. b) Ccnsider purchase of the small Omnidata $2CCX simulat:r f:r in-house c;eratar training. Send semecne to Canidata to evaluate its performarce and capability. Zechman/Tsaggaris - icng tarm. CTHER l. Precalculate the exa:t vol'.mes of critical piping runs and tanks frca varicus taps and capture in a pr:cedure. Such a precedure wculd have helped in quickly analyzing the pressurizer situation and in deternining the core remained covered. Mackey - May 11. 2. Escalate the alarm window correcticn program in priority. This will eliminate an excessive number of lighted ;anel alarms at the baseline condition and give the c; erat:r a better chance to focus on what to res;cnd to. Shcylin - en going 3. Add addi:icnal alarm ackncwiedgement ca: ability in tne : n:rol recm. Currently the :erator a: :te c:ntrols has to go across the c:ntrol to read an alarm and then back to ne center censole to ackncwiedge it. G?USC - Tecle - determine GFU ; sition v} 9 l'L '} r) 0 '\\ g e AF:E.'; DIX A: GF)^HS 3raph A - CT3G Level, 0T53 Fressure, and FW fica vs. time ,r a ; n. 3 - xC r-,icw vs. time e eraph C - 3C eressure and Pressurizer itvei vs. 6;*me 9 m Graph 0 - RC Pressure and Pressurizer level vs. time 3ra;h E - RC5 TE ;erature vs. time Gra:n F - Actual RCS Tema./Fress. C cidcwn vs. Limits for NFSH and Fuel ?in C: :ress1cn ,ra p h u, - r.c tua l eS i amo./.-res s. v s. (.a,a,mimits ter a ne C; era tion '). L. ~ ' L. -I3-

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