ML20003G048
| ML20003G048 | |
| Person / Time | |
|---|---|
| Issue date: | 03/25/1981 |
| From: | Carroll D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Wright G ILLINOIS, STATE OF |
| References | |
| NUDOCS 8104280132 | |
| Download: ML20003G048 (2) | |
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NUCLEAR REGULATORY COMMISSION o
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o 799 ROOSEVELT ROAD GLEN ELLYN, ILLINOIS 60137 o
MAR 2 51981 o
4 Illinois Department of p$
4AgO Nuclear Safety 9-ATTN:
Mr. Gary N. Wright
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Deputy Director (9,g q%hg/g '
1035 Outer Park Drive Springfield, IL 62704
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Gentlemen:
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The enclosed IE Information Notice No. 81-10 titled " Inadvertent Containment Spray Due to Personnel Error" was sent to the licensees listed below on March 25, 1981:
American Electric Power Service Corporation Indiana and Michigan Power Company D. C. Cook 1, 2 (50-315, 50-316)
Cincinnati Gas and Electric Company Zimmer (50-358)
Cleveland Electric Illuminating Company Perry 1, 2 (50-440, 50-441)
Commonwealth Edison C)mpany Braidwood 1, 2 (50-456, 50-457)
Byron 1, 2 (50-454, 50-455)
Dresden 1, 2, 3 (50-10, 50-237, 50-249)
LaSalle 1, 2 (50-373, 50-374)
Quad-Cities 1, 2 (50-254, 50-265)
Zion 1, 2 (50-295, 50-304)
Consumers Power Company Big Rock Point (50-155)
Palisades (50-255)
Midland 1, 2 (50-329, 50-330)
Dairyland Power Cooperative LACBWR (50-409) l Detroit Edison Company Fermi 2 (50-452)
Illinois Power Company Clinton 1, 2 (50-461, 50-462) l Wh 8104280 L
g Illinois Department of-1 Y Nuclear Safety Iowa Electric Light & Power' Company Duane Arnold (50-331).
Northern Indiana Public Service Company Bailly (50-367)
Northern States Power Company Monticello (50-263)
' Prairie Island 1, 2 (50-282,-50-306)
Public Service of Indiana Marble Hill 1, 2.(50-546, 50-547)
Toledo. Edison Company Davis-Besse 1 (50-346)
Union Electric Company Callaway 1, 2 (50-483, 50-486)
Wisconsin Electric Power Company Point Beach 1, 2 (50-266, 50-301)
Wisconsin Public Service Corporation Kewaunee (50-305)
Sincerely, 4
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lDorothyf,tatoll, Chief
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Word Proce'ssing and Document Control Section Enclosu.e:
IE Information Notice No. 81-10 cc w/ enc 1:
Mr. D. W. Kane, Sargent & Lundy Central Files Reproduction Unit NRC 20b AEOD Resident Inspector, RIII J. G. Keppler, RIII C. E. Norelius, RIII R. E. Heishman, RIII i
J. A. Hind, RIII P. R. Wohld, RIII PDR Local PDR NSIC 2
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SSINS No.:
6835 Accession No.:
g 8011040273 IN 81-10 UNITED STATES NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT WASHINGTON, D.C.
20555 March 25, 1981 IE Information Notice No. 81-10:
INADVERTENT CONTAINMENT SPRAY DUE TO PERSONNEL ERROR Description of Circumstances:
On February 11, 1981 while in mode 5 (cold shutdown), an auxiliary unit operator at Sequoyab Unit 1 misunderstood a verbal instruction and opened a single valve in the residual heat removal (RHR) system.
The opened valve created a direct flow path through the RHR system from the primary coolant system to the RHR containment spray header.
A rapid primary system depres-surization to atmospheric pressure resulted, and a total of about 110,000 gallons of water was sprayed into the containment from the primary system and from the refueling water storage tank (RWST).
Licensees and applicants should be aware of the following aspects of this event and should take appropriate steps to prevent a recurrence at their plant.
The auxiliary unit operator did not have adequate training or orientation at the particular duty station involved.
A single valve at that station is part of the primary coolant system pressure boundary when using the residual heat removal (RHR) system for shutdown cooling.
Thus, personnel / administrative problems and a plant design feature combined to cause the event.
Design of the control room annunciators contributed to prolonging the event.
The panel indicating emergency core cooling system (ECCS) valve positions is designed to warn when the ECCS is not properly aligned for the injection (safety) mode. When tk first valve misalignment occurs, one light comes on in an otherwise dark field of indicators, and an alarm sounds and flashes.
However, in the shutdown cooling mode, several valves are not in their injection mode position.
Therefore, in the event at Sequoyah, the alarm light had already been on continuously for some time, the annunciator was not supposed to operate, and one more light coming "on" in a valve position-indicating field with several lights already "on" was easily missed.
The operators thus failed to detect the presence of the inadvertently opened valve for at least 35 minutes.
Lack of an ECCS initiation procedure for use in the shutdown cooling mode did not significantly delay recovery from this event, but potentially could have done so had the primary system been at a higher pressure.
To provide injection flow for pressurizer level recovery, the operators opened the RHR sysetm suction valve from the RWST, but they neglected to close the RHR system suction 4
valves from the reactor coolant system (RCS).
A proper procedure would require those latter valves to be closed to prevent reactor pressure from seating a
IN 81-10 March 25, 1981 Page 2 of 2 check valve in the RWST suction line, which would prevent the injection mode for the low pressure (RHR) pumps from being effective and delay recovery from the event.
A similar problem with the borated water storage tank (BWST) check valve occurred at Crystal River 3 on July 16, 1980 while the unit was in Mode 5 with the decay heat system in use for shutdown cooling.
Improper valve alignment on the decay heat system heat exchangers caused a rapid cooldown of the RCS which resulted in a loss of pressurizer level.
When recovery was attempted by realigning the decay heat syste9 suction to the BWST, injection flow could not be established until RCS prestsre approached atmospheric conditions since the RCS suction valves remained open.
This problem would be particularly significant under a LOCA condition with the RCS temperature above boiling (Mode 4).
The information herein is being provided as an early notification of a pos-sibly significant matter that is still under review by the NRC staff.
Recip-ients should review the information for possible applicability to their facilities. If NRC evaluation so indicates, further licensee actions may be requested.
No written response to this information notice is required.
If you need additional information regarding this matter, contact the Director of the appropriate NRC Regional Office.
Attachment:
Recently issued IE Information Notices.
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Attachment IN 81-10 1[.,
March'25, 1981 RECENTLY ISSUED IE INFORMATION NOTICES InTormation Date of Notice No.
Subject Issue Issued to 81-09 Degradation of Residual 3/26/81 All power reactor Heat Removal (RHR) System facilities with an OL or CP -
81-08 Repetitive Failures of' 3/20/81 All power reactor Limitorque Operator SNB-4 facilities with an Motor-to-Shaft Key OL or CP 81-07 Potential Problem with 3/16/81 All power reactor i
Water-Soluble Purge Dam-facilities with an Materials Used During OL or CP Inert Gas Welding i'
81-06 Failure of ITE Model 3/11/81 All power reactor K-600 Circuit Breaker facilities:with an
' 0L or CP 81-05 Degraded DC System at 3/13/81 All power reactor Palisades facilities with an OL or CP 81-04 Cracking in Main Steam 2/27/81 All power reactor Lines facilities with an OL r
81-03 Checklist for Licensees 2/12/81 All power reactor Making Notifications of facilities with an j.
Significant Events in OL Accordance with 10 CFR 50.72 81-02 Transportation of 1/23/81 All Radiography Radiography Devices licensees 81-01 Possible Failures of 1/16/81 All power reactor General Electric Type facilities with an HFA Relays 0L or CP.
80-45 Potential Failure of 12/17/80 All PWR facilities BWR Backup Manual Scram with an OL or CP Capability 80-44 Actuation of ECCS in the 12/16/80 All PWR facilities Recirculation Mode While with an OL or CP in Hot Shutdown OL = Operating Licenses CP = Construction Permits
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