ML20023D822
| ML20023D822 | |
| Person / Time | |
|---|---|
| Site: | Salem  |
| Issue date: | 05/27/1983 |
| From: | BASIC ENERGY TECHNOLOGY ASSOCIATES |
| To: | |
| Shared Package | |
| ML20023D821 | List: |
| References | |
| NUDOCS 8306030351 | |
| Download: ML20023D822 (31) | |
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A REPORT ON A REVIEW OF PUBLIC SERVICE FLECTRIC AND GAS COMPANY CORRECTIVE ACTION PROGRAM RELATED TO REACTOR TRIP BREAKER FAILURES AT SALEM GENERATING STATION, UNIT NO.1 CONDUCTED BY BASIC ENERGY TECHNOLOGY ASSOCIATES, INC.
ARLINGTON, VIRGINIA MAY 27,1983 l
l 8306030351 830531 PDR ADOCK 0500027 S
TABLE OF CONTENTS PAGE I.
Executive Summary 1
II.
Introduction 2
l A.
Background
2 I
B.
Scope of BETA Review 3
C.
Review Approach 4
D.
Report Emphasis and Context 5
III. Conclusions 6
IV. PSE&G Short and Long Term Actions 7
A.
Introduction 7
B.
Short Term Actions 7
C.
Long Term Actions 8
1.
Summary 8
2.
Comments on PSE&G's Proposed Long Term Actions 8
3.
Additional BETA Findings and Recommendations 13 Appendices I.
BETA Letter to PSE&G dated April 14, 1983 II.
BETA Letter to PSE&G dated April 26, 1983 III. Attachment 1 to PSE&G Letter to NRC dated April 28, 1983 i
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EXECUTIVE
SUMMARY
This report provides the results of an independent review conducted by Basic Energy Technology Associates, Inc., (BETA). The review was made of corrective actions identified by Public Service Electric & Gas Company (PSE&G) as being necessary to assure continued safe operation of the Salem Generating Station in view of the incidents at Unit No. I where reactor trip breakers failed to open automatically.
The BETA review concludes that satisfactory accomplishment of the short and long term corrective action program, as outlined by PSE&G along with a number of additional actions recommended by BETA, should provide the necessary assurance that the immediate and underlying causes of the breaker problems have been solved.
BETA considers these actions to be appropriate and necessary.
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H.
INTRODUCTION A.
BACKGROUND On February 25, 1983, the reactor trip breakers on Unit 1 of PSE&G's Salem Generating Station failed to open automatically following receipt of' trip signals from the Reactor Protection System.' The reactor plant operators manually shut down the reactor safely within-30 seconds of the automatic trip. No equipment damage or personnel radiation exposure resulted from this incident.
Following this event, it was determined that a similar failure occurred during an automatic reactor scram on February 22, 1983. Reactor shutdown at that time also was a result of manual reactor operator action.
PSE&G determined that both of the failures to trip automatically were the result of malfunctions of the reactor trip breaker's undervoltage trip.
attachments (UTA's).
As a result of these failures to trip, Unit I was placed in a cold shutdown condition and both PSE&G and the U.S.
Nuclear Regulatory Commission (NRC) initiated detailed investigations of the incidents. These reviews were directed towards determining the underlying causes, management and operational, related to the failures to trip automatically and to determine what actions were necessary to preclude or protect against a recurrence of these or similar events. All areas associated with these events, including management, maintenance, procurement, operations, training, quality assurance and engineering design were reviewed.
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B.
SCOPE OF BETA REVIEW As part of its review of the incidents, PSE&G engaged Basic Energy Technology Associates (BETA) of Arlington, Virginia, on April 5,1983, as an independent consultant. BETA was tasked to review PSE&G's investigation of the events of February 22 and 25,1983, including its corrective action program as outlined in an April 8,1983, PSE&G report to the NRC. BETA was requested first to make an independent evaluation of PSE&G's action plan and to advise PSE&G on the adequacy of those short term corrective actions which were to be taken prior to the restart of Units 1 and 2.
Salem Unit 2 was in a shutdown condition for refueling and was not available for restart until some time after Unit I restart. The results of this phase of the review were contained in BETA's letter dated April 14,1983, (Appendix I of this report). The second phase of the BETA review was to determine the appropriateness and adequacy of the long term actions identified by PSE&G.
The completion of this second phase of the review was to be accomplished as soon as possible after completion of the first phase.
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C.
REVIEW APPROACH The BETA review took place during the period from April 5 to May 15, 1983. - The four BETA Associates; R. W. Bass, R. S. Brodsky, M. E. Miles and W. Wegner participated in the review. BETA also obtained the assistance of an independent consultant, a specialist in electrical matters, 'J. C. Grigg.
In addition to reviewing the written background material available from PSE&G, visits were made to the site by the above individuals. During these visits, tours of the plant were made and personnel interviews were held with all levels of management and senior operating personnel.
The equipment and procedures associated with the incident were also reviewed. A member of the group attended a meeting of the Station Operating Review Committee.
At PSE&G's request, BETA attended the NRC meedngs on April 14 and 26, 1983, concerning this incident.
l The BETA review concentrated on those areas related to the breaker incident, the resulting PSE&G and NRC investigations, and the proposed PSE&G corrective action program, both short and long term. In doing so, BETA did not attempt. to confirm that the specific corrective actions identified by PSE&G and NRC had been completed or that they were being performed satisfactorily.
Instead, the BETA review concentrated on evaluating the appropriateness and adequacy of the actions identified as i
i being necessary to remedy the original deficiencies brought to light by the incidents. Since a number of the long term corrective actions dealt with issues broader than the specific breaker problem, such as management, the BETA review-was expanded and those areas, where appropriate, are addressed in this report, 4
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D.
REPORT EMPHASIS AND CONTEXT PSE&G has operated the Salem reactor plant safely since 1977. In so doing, they have developed and applied many sound methods and practices for carrying out these activities in a safe manner.
BETA found evidence of strengths in plant operation which have their basis in this experience.
Nevertheless, a report such as this, by its very nature, emphasizes shortcomings and areas where improvements can be made.
As would be expected, the discussion that follows concentrates on those areas BETA has identified where it is believed additional or different actions are appropriate.
Actions proposed by PSE&G which BETA considers appropriate or satisfactory are not specifically discussed in this report.
b I
III.
CONCLUSIONS This report presents the results of BETA's review. Specific findings
-and recommendations are included.
As previcusly noted, BETA provided written recommendations relating to short term actions to PSE&G in a BETA letter dated April 14, 1983. On April 26, 1983, BETA provided PSE&G with an additional letter on this subject (Appendix II) which discussed the implications of the discovery on April 20,1983,,of a broken tab on a newly installed undervoltage trip attachment (UTA) in a Unit 2 trip breaker. This letter confirmed that BETA's findings reported in its April 14, letter had not changed as a result of this event.
BETA considers that the PSE&G corrective action program, suppleriented by BETA's recommendations contained in this report, constitutes a satisfactory response to the trip breaker incident and is an acceptable basis to conclude that Salem Units 1 and 2 can be safely returned to power insofar as the trip breaker incident is concerned.
During its investigation BETA identified no weakness that would indicate power operation should not be resumed.
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IV. PSE&G SHORT AND LONG TERM ACTIONS A.
INTRODUCTION The attachment to PSE&G letter to the NRC dated April 28, 1983, included a summary listing of short and long term actions relating to the reactor trip breaker events of February 22 and 25,1983. Appendix III of this report includes this PSE&G listing.
B.
SHORT TERM ACTIONS With respect to the short term action items proposed by PSE&G, the BETA letter of April 14,1983 (Appendix I) stated that:
"The short term actions taken by PSE&G as outlined in the April 8,1983, Supplement I Report are appropriate and should, along with the two short term actions recommended by BETA, provide reasonable - assurance that the immediate problems associated with the events leading to reactor breaker trips on February 22 and 25, should not recur prior to completion of the long term actions."
In addition, the BETA letter included. the following recommendations relative to the short term actions:
"1.
PSE&G should obtain confirmation in writing from the reactor trip breaker vendor that the installed breakers are satisfactory for plant operation and that Salem Maintenance Procedure M3Q-2 will provide the necessary basis to assure continuing operational reliability.
2.
PSE&G's Station Operations Review Committee and the Nuclear Review Board should complete their reviews of the short term aspects of the trip breaker failures. Written reports should be available documenting their concurrence with restart."
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The short and long term action items contained in the original April 8, 1983, PSE&G report were slightly changed in the PSE&G letter of April 28,
~.1983, and its attachment. These changes should result in improved equipment reliability and therefore do not change BETA's original conclusions as outlined above.
C.
LONG TERM ACTIONS 1.
SUMMARY
On the basis of its review, BETA has not identified any new or additional areas that could have contributed to the breaker failure. On the '
whole, BETA considers that the long term actions proposed by the PSE&G letter of April 28, 1983, as modified by the BETA comments that follow, are satisfactory and should provide a reasonable assurance that a failure to trip will not occur in the future as a result of simultaneous trip breaker failures.
As a result of its review, BETA has developed two categories of recommendations. The first category discussed in IV.C.2 below, adddresses the specific long term actions identified by PSE&G. The second category of recommendations, IV.C.3 below, presents additional actions that BETA, based upon its review, considers desirable.
2.
COMMENTS ON PSE&G's PROPOSED LONG TERM ACTIONS a.
Lonst Term Action (BETA proposed)
BETA's letter of April 14,
- 1983, had the following recommendation concerning PSE&G's proposed long term action plan:
"The Salem breaker maintenance procedure, M3Q-2, will use periodic measurements of trip and release forces to identify degradation of breaker performance. As another indicator of possible breaker degradations, PSE&G should consider the use of the periodic data obtained from the voltage 8
dropout measurements which are also in the breaker maintenance procedure (step 9.7.3.10)."
This recommendation has been incorporated into the final action plan.
b.
Long Term Action (Item A.2.b.1)1
" Submit a test program with provisions for a statistically significant sample to determine the life cycle and replacement interval for the UTAs and to verify the adequacy of the new maintenance and surveillance programs used on the reactor trip circuit breakers - May 1983" BETA Recommendation Establishing the cycle
- life, replacement interval and development of maintenance and surveillance programs for the UTA's (and the breaker itself) should be the responsibility of the component vendors.
The vendors not only have the design experience, but also have access to a larger operating experience base than is available to PSE&G. In addition, if the vendors are responsible for developing these parameters, there is some assurance that the results will be extended, as necessary, to engineering modifications incorporated in replacement components.
PSE&G should request that the breaker vendors supply the recommended life cycle, replacement interval, and the recommended maintenance and surveillance programs. In addition, the vendors should be able to supply the necessary technical information to support these recommendations. In the interim:
1.
(NOTE: The item reference refers to Attachment 1 to PSE&G letter of April 28, 1983) 9
(1) PSE&G should select a conservative replacement interval and periodically replace the UTAs.
(2)
Use its new maintenance and surveillance programs to maintain the equipment and monitor its performance.
c.
Long Term Action (Item A.S.B)
"Providing at the Salem facility diversity in activating (tripping) the reactor trip breakers, for example, by incorporating the breaker shunt trip function into the automatic trip circuits of the reactor protection system."
BETA Recommendation BETA recommendations with respect to the above long term action item were contained in the attachment to BETA letter of April 14, 1983, and still apply. They were:
(1) The manual trip switch trips both the undervoltage and shunt trips. In order 'to provide a greater assurance of breaker action, it is suggested that the automatic trip also use the shunt trip device.
The automatic trips use only the undervoltage trip. A safety grade power supply will be required to support the shunt trip. It is understood that PSE&G is investigating the feasibility of providing a shunt trip.
(2) In order to further decrease the possibility of a common mode failure, consideration should be given to replacing one of the two sets of installed breakers with breakers or contactors of another design or manufacture.
If possible, the breaker design should incorporate a molded case. if an alternate device is selected it should be included in the PSE&G and NRC test programs.
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d.
Long Term Action (Item B.3.b.2)
" Modifications to clarify first-out annunciator alarms."
' Discussion The design of the first-out annunciator alarm is such that, under some transient conditions, the annunciator may latch and alarm even though the input signal has cleared and a reactor shutdown is not required and has not occurred. Because of this response characteristic it is necessary to evaluate first-out annunciator alarms to confirm that a valid reactor shutdown requirement accompanies the alarm. The procedures are such that the operator will confirm the validity of the first-out alarm by reviewing the Solid State Protective System (SSPS) status panel indicators.
The indicators on this panel will confirm the validity of the shutdown signal. If the signal is valid, the operator will back-up the automatic trip by initiating a manual trip.
BETA considers that the actions taken and proposed by PSE&G will improve the protection available from the operator in the future in the unlikely event an ATWAS occurs. However, BETA believes it is important that operators believe their instruments and that equipment design support this concept.
BETA Recommendation If possible, the first-out annunciator panel and SSPS should be modified to assure that the first-out annunciator panel alarms latch only when accompanied by a valid trip of the SSPS.
The ATWAS procedures should then be changed to require a manual trip in the event the first-out annunciator panel alarms without requiring verification of the validity of the alarm.
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e.
Long Term Action (Item C.10.a)
" Nuclear Oversight Committee (NOC)"
Discussion PSE&G intends to establish a Nuclear Oversight Committee to provide management with an independent basis for evaluating the effectiveness of nuclear safety. The Committee will include three to five members and will consist of nuclear utility operations executives, college professors and former regulators.
The Nuclear Oversight Committee will submit reports to the Vice President - Nuclear following each quarterly meeting.
Reports will include: (1) an evaluation of overall management attention to nuclear safety, (2) progress being made toward resolving the open issues identified in the commitments made by PSE&G to the Nuclear Regulatory Commission and (3) progress on action items resulting from Management Analysis Company's evaluation.
Copies of these reports will be forwarded to the Nuclear Regulatory Commission.
BETA Recommendation BETA concurs with the desirability of obtaining outside overview relative to the operation of the Salem plants. Such an input can provide a valuable stimulus to the management and staff. However, BETA does not consider it necessary nor desirable to establish another committee to obtain this objective.
PSE&G already has a Nuclear Review Board, a Station Operators Review Committee, and a Safety Review Group.
In addition, a Nuclear Assurance and Regulation Department has recently been l
established. To some extent, the functions of these groups, including the l
proposed NOC, overlap and each group's operations will impose some demands l
on the resources available for plant operation.
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BETA recommends that the Nuclear Review Board (NRB) niembership be changed to increase its independence from plant operations and to provide a greater outside input to its activities. The outside input proposed for the NOC should, instead, be located within the NRB. PSE&G membership on the board should be limited to management personnel not having direct responsibility for plant operations.
Board reviews could be supplemented by the use of subcommittees utilizing plant staff.
The proposed objectives of the NOC, where different from the NRB, could be incorporated into the NRB.
It is believed that this outside input plus a greater emphasis by management on the importance of the newly structured NRB could improve its effectiveness without placing a greater burden on the activities of the plant operating staff.
3.
ADDITIONAL BETA FINDINGS AND RECOMMENDATIONS a.
Finding The major organizational change PSE&G embarked on in October 1981, is well-founded and appropriate but continued effort is needed to assure these changes are meeting the intended goals.
Discussion The concept and goals of the major organizational changes started by PSE&G in October 1981, should provide PSE&G with a more effective and well-functioning organization. In its review, BETA found a number of cases where the organizational changes had been made but the implementation, particularly at the lower levels of the organization, was in need of continuing effort by management to effect the total intent of the change.
The primary purpose of the change was to provide improved responsiveness and dedication. ~ support people to plant operations by combining nuclear personnel into a single organization located at the site.
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This, essentially, has been done.
PSE&G saanagement needs now to concentrate its effort on making this new organizational concept work better.
There still exists situations where better understandings are needed between the operating plant and those organizations which support it. Areas needing improvement include engineering, quality assurance, radiation protection and material management.
PSE&G is aware of this situation and has taken action in each case.
Recommendation PSE&G senior nuclear management should develop a better capability to determine how well their new organizational plan is functioning, particularly at the lower levels. Where it is found lacking, corrective action should be taken. This may mean slightly altering the organizational plan.
BETA agrees with the PSE&G plan to achieve better coordination between the divisions by greater use of rotation of personnel between the divisions.
This will become even more important as the Hope Creek plant gets closer to operation.
b.
Finding Changes to procedures were made to assure testing of the breakers prior to a startup. PSE&G did not fully extend this concept of additional testing to other safety related equipment.
Discussion As a result of the events preceding the trip breaker failure, PSE&G modified its operating procedure IOP-3 " Hot Standby to Minimum Load".
This modification included the requirement that a Reactor Trip Breaker functional test be completed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of reactor startup.
This test was over and above all other testing already required by the plant's 14
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TechnicalSpecifications and existing procedures. This additional test provides greater assurance that this equipment'important to safety is operable. This concept of additional testing prior to startup could be extended to other equipment important to safety.
Recommendation PSE&G should review existing pre-start test requirements to determine if additional testing of safety related components or systems is desirable. In addition, this review should also be extended to pre-startup status checks.
c.
Finding As stated in PSE&G's April 8,
1983 report, the Station Operations Review Committee (SORC) effectiveness needs enhancement.
Discussion Based upon its review of a SORC meeting, BETA concurs in PSE&G's efforts to increase the effectiveness of this committee.
The following recommendations are some actions that could be taken to achieve this PSE&G objective.
Recommendations
(_1) The minimum number of full time members required to constitute a quorum should be increased.
(2) A senior management representative of Nuclear -
Engineering should be made a full-time member of the Committee.
(3) Items requiring Committee review should be reviewed and concurred in by the appropriate inter-departmental organizations prior to being forwarded to SORC for review. The PSE&G administrative procedure 15
for SORC should be revised to assure these technical (including nuclear engineering) and operational reviews are performed prior to SORC review.
d.
Finding.
The number of unplanned reactor trips at the Salem plants exceed an average of one per month.
Discussion An important factor in assuring the safe operation of a reactor plant is to maintain operation within the normal control band. Challenges to the protective system should be considered undesirable. The first line of plant protection is the operator and the operating procedures; the protective system is a backup.
PSE&G has shown they recognize the importance of unplanned reactor trips by recent changes they have instituted at Units 1 and 2 which should significantly reduce the frequency of these trips.
Recommendation PSE&G should continue their efforts to reduce the number of unplanned reactor trips at the Salem plants, e.
Finding The machinery history records are not in a form which readily permits the effective use of the information contained in these records.
Discussion The machinery history records are not organized by component.
They are a sequential list of individual work items. In order to determine what work has been performed on a component, the entire tabulation of work records must be reviewed.
This limits the effective use of these records for trend analysis or as a diagnostic tool.
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Recommendation PSE&G should develop a data base which would permit using the machinery history records to analyze and evaluate equipment problems.
f.
Finding The Salem incident report system should be strengthened.
Discussion PSE&G has an incident report system (Administrative Procedure No. 6).
This system, when combined with an Event Narrative Report (ENR), provides a satisfactory basis for assuring follow-up on major incidents. However, the ENR is generated only in the event a Licensee Event Report (LER) is required. The incident report relles on the ENR to determine root causes of incidents. In addition, the instructions requiring the generation of a'n incident report restrict its use to a class of " safety" related events.
Other incidents such as certain classes of electrical component failures would not, in the past, be covered by this system.
Recommendation Administrative Procedure No. 6 should be expanded.
The procedure should be applied to a broader class of events. In addition, an ENR should be prepared for each incident report.
g.
Finding PSE&G's Nuclear Engineering Department needs to be more closely tied to the operational aspects of the plant.
Discussion Although PSE&G has taken action to move the support engineering organization to the plant site, further effort is required to assure 17
that it is interacting as effectively as it could with the operations staff.
The engineering staff needs to be more actf.vely involved in the day-by-day plant problems.
Recommendation Continued action should be taken to integrate more fully the nuclear engineering organization into plant operations.
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BASIC I
I
= = ~cc~1= u w' s2s 17o0 N. Mooxt Srstat' ENERGY A"s;M:;a"a;~"222
- TECHNOLOGY ASSOCIATES, INC.
April M,1983
\\1r. Richard M. Eckert, Chairman Public Service Electric & Gas Company 80 Park Place Newark, New Jersey 07101
Dear \\1r. Eckert:
In acccedance with your request of April 5,1983, BETA began an independent review of the adequacy of the actions being taken by PSE&G as a result of the recent reactor breaker trip incidents at the Salem Generating Station.
We have completed the preliminary phase of this review and, as you directed, we are attaching herewith our report covering the work performed to date.
We intend to continue our review of the adequacy of the long term actions and will provide you a report upon completion of that effort.
Sincerely, 13FL W. Wegne' Associa A ttachm ent APPENDIX I
ATTACILVENT I. TO PSE&G LETTER TO NRC DATED APRIL 28, 1983 ATTACHMENT 1 PSE&G CORRECTIVE ACTION REPORT SHORT AND LONG TERM ITEMS ITEM COMPLETION A.
EQUIPMENT ISSUES A.1 Determination of Safety Classification of Breakers Complete A.2 Identification of Cause of Failure a.
Short-Term Actions 1.
Confirm that new U/V trip attachments Complete on Salem Units 1 & 2 incorporate all design changes made to these devices.
2.
Measure and confirm the force required Complete to trip the breakers via the trip bar is less than < 31 ounces.
b.
Long-Term Actions
/1.
Submit a test program with provisions for a statistically significant sample to determine the life cycle & replace-ment interval for the UTAs & to verify the adequacy of the new maintenance & surveillance programs used on the reactor trip circuit breakers May 1983 2.
Establish a procedure for periodically Complete measuring the force required to trip the breakers.
/ A. 3 Verification Testing Program a.
Short-Term Actions 1.
Manufacturer.will electrically test U/V trip attachment on Test CB 25 times.
Complete 2.
After installation, U/V trip attachment tested 10 times.
Complete APPENDIX III
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ITEM COMPLETION 3.
After installation in appropriate breaker compartment, Response Time Test.
Complete 4.
Test for independent operation of UV attachment and shunt trip coil within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> prior to restart from each shutdown.
Complete A.4 Maintenance and Surveillance Procedures a.
Short-Term Actions
- 1.
Resolve breaker cabinet /switchgear room cleaning deficiency.
Complete 2.
Revise maintenance procedure and/or other documents to require all replacement U/V attachments to have been successfully tested by the manufacturer 25 consecutive cycles.
cycles.
Complete 3.
Provide acceptance criteria in Maintenance Procedure M3Q-2 for ten cycle test that allows N0 failures for acceptance.
There will be a 30-minute interval between each test.
Complete 4.
Modify Maintenance procedure M3Q-2, Section 9.8 to include three timing tests and an average time computed for comparison to previous tests.*
Complete 5.
Revise Maintenance Procedure M3Q-2, Section 9.7 & other appropriate procedures to require that a sealant l
be applied to the head of the self-l locking screw on the U/V attachment.
Complete l
l 6.
Specify in Maintenance Procedure M3Q-2, the acceptable range of U/V coil dropout voltage & actions to be taken if out of specification.*
Complete 7.
Lubricate the circuit breakers and UV trip attachments in accordance with W Technical Manual.*
Complete "See attached Table 1.
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F ITEM COMPLETION 8.
Perform a trip force measurement on the trip bar of each breaker.*
Complete 9.
Modify maintenance procedure to test bypass breakers every 6 months.*
Complete 10.
Provide functional test procedures for UV trip, shunt trip, and manual scram.*
Complete
- 11. Perform monthly reactor trip breaker timing test.*
Ccmplete b.
Long-Term Actions v/1.
Propose Technical Specifications Within 30 days to include reporting and Table 1 of Unit S/U requirements.
Issuance of technical specification change will supersede Table 1.
A.5 By July 15, 1983, the licensee shall submit to the Director, Office of Nuclear Reactor Regulation a deta'iled report describing either how and on what schedule the following actions will be accomplished, or why any of these actions should not be taken.
Implementing at the Salem facility (Units 1 and 2) the following a.
feature of the proposal by the Industry Group on ATWS submitted on April 23, 1982, on Docket PRM-50-29 (page 10 of Appendix C):
provision of automatic initiation of turbine trip and auxiliary feedwater independent of the reactor protection system; b.
Providing at the Salem facility diversity in activating (trip-p'ng) the reactor scram breakers, for example, by incorporating the breaker shunt trip function into the automatic trip circuits of the reactor protection system.
B.
OPERATOR PROCEDURES, TRAINING, AND RESPONSE B.1 Operating Procedures for ATWS a.
Short-Term Actions 1.
Identify indications in control room providing positive identifi-cation of reactor trip demand.
Complete "See attached Table 1.
ITEM COMPLETION 2.
Review the basis for ATWS procedure steps and order of priority, revise procedures, as necessary, and train operators.
Complete b.
Long-Term Actions 1.
Provide detailed description of procedures to ensure operability of SSPS status panel indicators.
Complete 2.
Provide schedule for the upgrade program for Emergency Operating Procedures Complete B.2 Operator Training a.
Short-Term Action 1.
Conduct training for operators on revised procedures.
Complete 2.
Conduct practical exerc'se in Control Room of revised procedures.
Complete 3.
Conduct walkthrough on alarms &
RPS indicators.
Complete 4.
Conduct training for auxiliary operators Complete 5.
Evaluate trainees' performance against established objectives Complete 6.
Review training material and ensure it is current and properly referenced Complete B.3 Operator Response a.
Short-Term Action 1.
Caution operators in use of J handle control.
Complete b.
Long-Term Actions J 1.
Replace Reactor Trip Switch Complete with secure handles J 2.
Modifications to clarify first-out complete annunciator alarms
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ITEM COMPLETION C.
MANAGEMENT CAPABILITY AND PERFORMANCE C.1 Master Equipment List (MEL) a.
Short-Term Actions 1.
Verify MEL is complete & accurate with respect to ECCS, including actuation systems, RPS, Aux. Feedwater and containment isolation systems.
Complete 2.
Instruct appropriate personnel in purpose & use of MEL.
Complete b.
Long-Term Actions 1.
Verify completeness & accuracy of MEL for remaining Q list systems and re-issue as a controlled document.
May 1983 C.2 Procurement Procedures a.
Short-Term Actions 1.
PSE&G Sampling review of past procure-ment documents Complete b.
Long-Term Actions 1.
Evaluate & modify procurement procedures to ensure appropriate classification of items / services important to safety.
July 1983 C.3 Work Order Procedures a.
Short-Term Actions 1.
QA Department review all nonsafety-related work orders prior to starting work.
Complete 2.
Conduct a training program to ensure that work orders are properly classified.
Complete 3.
Review work orders written since issuance of the MEL for proper classification & evaluate safety consequences of those found improperly classified.
Complete
o ITEM COMPLETION C.4 Post-Trip Review a.
Short-Term Actions 1.
Develop and implement Post Trip Review Procedure AD-16 Complete C.5 Timeliness of Event Notification a.
Short-Term Actions 1.
Assign dedicated communicator to each Complete shift.
2.
Review importance of reporting require-ments with supervisors Complete C.6 Updating Vendor-Supplied Information a.
Short, Term Actions 1.
Update existing documentation on safety equipment and ensure that vendor docu-mentation is ender a controlled system.
a) Audit Station files for manuals existence, revision level, and date.
Complete b) Audit Nuclear Engineering files for manuals existence, revision level, and date.
Complete c) Compare Station & Nuclear Engineer-ing; Audit and use latest manual revision Complete d) - Contact vendors to confirm that manuals are technically current Complete
- Request updated copies Complete 2.
Review Westinghouse Technical Bulletins and Data Letters Complete b.
Long-Term Actions a) Audit Station files for manuals existence, revision level, & date June 1983 b) Audit Nuclear Engineering files for manuals existence, revision level, and date.
July 1983
ITEM COMPLETION c) Compare Station & Nuclear Engineer-ing; audit and use latest manual revision Aug. 1983 d) Contact vendors to confirm that manuals are technically current, Dec. 1983 and request updated copies (where identified as more recent) e) Revise Station procedures where appropriate July 1983 f) Index & control new/ revised manuals received Dec 1983 g) Develop procedures for controlling vendor manuals May 1983 C. 7 Involvement of Quality Assurance Personnel With Other Departments a.
Short-Term Actions 1.
Retain outside consultant to assess QA program Complete 2.
Modify QA organization policy to more fully integrate with overall nuclear activities Complete b.
Long-Term Actions 1.
Provide additional detail training on processing work orders to re-emphasize QA test / retest requirements September 1983 C. 8 Post Maintenance Operability Testing a.
Long-Term Actions 1.
Review and revise AP-9 and other station procedures July 1983 2.
Complete review of vendor and Engineering recommendations and incorporate necessary changes into departmental documents January 1984 3.
Incorporate items identified into Inspection Order System Aug. 1983
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ITEM COMPLETION
- 4.
Complete Managed Maintenance Program Jan. 1984 C.9 Overall Management Capability & Performance
/1, Complete staffing of Nuclear Assurance & Regulation Department Jan. 1984
/2.
Independent assessment of QA Operations July 1983
-3.
Implement training program for first-level supervisors Sept. 1983 s/4.
Develop training program for senior supervisory level Oct. 1983
- 5.
Develop program for periodic or regular training for supervisory and managment personnel Spring 1984
'6.
Develop Technical Training Program for non-Station personnel Spring 1984
-7.
MAC management diagnostic -
final report Jun'e 1983 C.10 Management Reports va.
Nuclear Oversight Committee (NOC) 1.
The NOC will provide copies of its Quarterly reports to the Senior Vice President, Energy Supply & Engineering, and, at the same time, ta the Director of Nuclear Reactor Regulation (NRR).
2.
PSE&G will provide to the Director -
Within 30 days NRR with its response to the report, of receipt of each NOC report.
3.
This provision will continue in effect until modified by the Director, NRR.
/ b.
Management Analysis Company (MAC)
ITEM COMPLETION 1.
PSE&G will provide to the Director - NRR Within 60 days an analysis of each recommendation made of receipt of MAC by MAC, the action to be taken in response appraisal to each, and a schedule for implementation.
s' c.
BETA Corporation 1.
PSE&G will submit to the Director - NRR Complete a copy of the' review conducted by the BETA Corporation of PSE&G's investigation of the events of February 22 and 25,1983 and of the corrective action program as described in PSE&G's April 8 submittal.
D.
INITIAL STARTUP AFTER FEBRUARY 25, 1983 EVENT Before entering any new mode, all systems and components required to be operable for that mode, in accordance with Technical Specifications, shall be reviewed to confirm operability.
has not been shown to be operable within 30 days prior to AprilIf all or pa 28, 1983, a review shall be conducted to determine if maintenance or other activity has taken place on such system or component since the last operability confirmation.
If such maintenance or other activity has taken place, operability shall be verified by applicable surveillance testing and/or preparation of a written analysis, avnilable for NRC inspection, demon-strating that the system or component is capable of performing its intended function.
This procedure will be followed until the first entry into Mode 1 for each unit subsequent to April 28, 1983.
m TABLE 1 PERIODIC SURVEILLANCE / MAINTENANCE OF REACTOR TRIP BREAKERS s
PRE-STARTUP MONTHLY 6-MOS.
(< 24 hra)
SURVEILLANCE SURVEILLANCE / MAINTENANCE (Main Trip Breakers)
(Main Trip Breakers)
(Main & Bypass Breakers) 1.
functional test of UV 1.
a.
SSPS functional of UV 1.
response time testing (3 times)
(via SSPS)
(visicorder) trend data b.
response time testing of UV/ breakers (event recorders) 2.
functional test of Shunt 2.
functional test of Shunt 2.
trip bar lift force measurements (manual controls)
(manual controls) 3.
functional manual scram switch (voltmeters) 3.
UV output force measurement 4.
drop-out voltage check 5.
servicing / lubrication / adjustments 6.
re peat testing steps 1-4 l
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A REPORT ON A PRELIMINARY REVIEW OF PUBLIC SERVICE ELECTRIC AND GAS COMPANY CORRECTIVE ACTION PROGRAM RELATED TO REACTOR TRIP BREAKER FAILURES AT SALEM GENERATING STATIOli, UNIT NO.1 CONDUCTED BY BASIC ENERGY TECHNOLOGY ASSOCIATES, INC.
ARLINGTON, VIRGINIA APRIL 14,1983
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1.
BACKGROUND On April 5,1983, Basic Energy Technology Associates, Inc. (BETA) was contracted by Public Service Electric and Gas Company (PSE&G) to conduct an independent evaluation of the corrective actions taken or planned by PSE&G as a result of the events surrounding the reactor breaker trip incidents of February 22 and 25,1983.
BETA was requested to initially concentrate its efforts on the short term actions taken by PSE&G as they would apply to the restart of Unit 1 and to provide an interim report outlining its findings and recommendations by April 14, 1983.
Due to this tight time constraint,. BETA in its initial review, has focused its effort on those short term actions taken by PSE&G as outlined in its Supplement ! Report dated April 8,' 1983.
This phase of the review was performed by two BETA associates, Robert S. Brodsky and William Wegner, in addition, BETA engaged the services of Jack C. Grigg, an independent consultant with over thirty years i
of reactor electrical control and instrumentation experience and specifically with reactor trip breakers, to assist in the performanes of this evaluation.
This report provides recommendations resulting from the BETA review to date.
A more comprehensive report will be provided to PSE&G upon completion of the final review.
1 II.
SUMMARY
OF FINDINGS AND RECOMMENDATIONS Based on the limited review conducted by BETA as previously described, the following summary of findings and recommendations are provided. Section 111 provides more detailed findings and recommendations.
1.
The identification of the known and probable causes leading to the breaker failures as outlined in the April 8 Supplement ! Report appears to be reasonable. At this time BETA has not identified any additional problem areas that have not already been identified by PSE&G or the Nuclear Regulatory Commission relating to this problem. BETA also considers that the actions listed as being short term (prior to restart) are adequate. Two additional short term actions, as outlined in Section !!! of this report, are recommended.
2.
The short term actions taken by PSE&G as outlined in the April 8, 1983 Supplement 1 Report are appropriate and should, along with the two short term actions recommended by BETA, provide reasonable assurance that the immediate problems associated with the events leading to reactor breaker trips on February 22 and 25, should not recur prior to completion of the long term actions.
3.
Interviews conducted by BETA of 16 PSE&G people at the site indicate a good understanding and appreciation of the problems which lead to the breaker trip incidents. The scope of the longer term actions would l
indicate there is also an appreciation for how these problems reflect on broader issues of the plant's overall operation. At this point, BETA is not in 1
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r a position to comment on the adequacy or completeness of the long term actions or on how deeply into the organization these understandings prevail.
There is some concern by BETA that the majority of corrective actions taken so far have concentrated specifically on problems directly associated with the breakers rather than on some of the broader aspects. This is an area that BETA will pursue in greater detail in subsequent evaluations.
4.
While post-incident investigations correctly identified a number of weaknesses throughout the PSE&G operation, BETA is of the opinion that there still exists a possible generic problem with breakers of this design and used in this application.
Specific recommendations relating to additional long term improvements with respect to the breakers themselves are contained in Section 111 of this report.
111. DETAILED FINDINGS AND RECO5131ENDATIONS A.
Short Term Findings and Recommendations 1.
PSE&G should obtain confirmation in writing from the reactor trip breaker vendor that the installed breakers are satisfactory for plant operation and that Salem Staintenance Procedure 313Q-2 will provide the necessary basis to assure continuing operational reliability.
2.
PSE&G's Station Operations Review Committee and the Nuclear Review Board should complete their reviews of the short term aspects of the trip breaker failures. Written reports should be available documenting their cencurrence with restart.
B.
Long Term Findings and Recommendations (Interim) 1.
The manual trip switch trips both the under voltage and shunt trips.
In order to provide a greater assurance of breaker action, it is suggested that the automatic trip also use the shunt device. The automatic trips use only the under voltage trip. A safety grade battery power supply will be required to support the shunt trip. It is understood that PSE&G is investigating the feasibility of providing a shunt trip.
2.
In order to further decrease the possibility of a common mode failure, consideration should be given to replacing one of the two sets of installed breakers with breakers or contactors of another design or manufacture. If possible, the breaker design should incorporate a molded case. If an alternate device is selected it should be included in the PSE&G and NRC test programs.
3.
The Salem breaker maintenance procedure, 3130-2, will use periodic measurements of trip and release forces to identify degradation of breaker per formance. As another indicator of possible breaker degradation, PSE&G should consider the use of the periodic data obtained from the voltage drop-out measurements which are also in the breaker maintenance procedure (step 9.7.3.10).
2
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4.
The PSE&G specifications for trip breakers should be modified to indicate that mounting brackets for over current trips should not be installed.
5.
Additional experimental data is necessary to confirm that maintenance procedure M3Q-2 testing will provide a satisfactory indication of breaker degradation.
This data should be obtained from the planned PSE&G and NRC testing.
6.
Breaker maintenance procedure M3 Q-2 will result in the trip breakers undergoing a large number of cycles. The PSE&G, NRC and vendor test programs should confirm that these tests will not result in the breaker exceeding breaker design cycle limits. In addition, the number of breaker cycles should be determinable and recorded.
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RoSSI.YN CENTER. SulTc 025 17oO N. Mooxt STREET ENERGY A"oM a%"o'a"" 2220.
TECHNOLOGY ASSOCI ATES, INC.
April 26,1983 Mr. Richard M. Eckert Senior Vice President Public Service Electric & Gas Company 80 Park Place Newark, New Jersey 07101
Dear Mr. Eckert:
This letter is in response to your request of April 22, 1983 asking whether or not BETA continues to support our letter to you of April 14, 1983, in light of the discovery on April 20, 1983, of the broken tab on a newly installed undervoltage trip assembly in Unit 2.
The April 14, 1983 BETA letter contained findings and recommendations concerning the reactor trip breaker incidents at the Salem Generating Station.
As a result of your request, three representatives of BETA visited the Salem site on April 25,1983, in order to review the circumstances surrounding this broken tab. This review consisted of interviewing PSE&G people, reading the investigative reports, and viewing the physical evidence, including photographs of the broken trip device.
Based on this review, BETA continues to support its findings and recommendations as contained in our April 14, 1983 letter to you.
In addition, we do not have any additional short term action items which, in our opinion, need to be accomplished prior to restart.
This conclusion is based on the following considerations:
1.
In BETA's opinion, the newly established procedures for installing and testing reactor trip breakers and equipment attached thereto would, and in fact did prevent the use of the malfunctioning device.
Disregarding the question of when the breakage actually occurred, i.e., in shipment from the vendor or elsewhere, the ultimate test is performed with the unit installed, and, as presently written, tnis test would have detected the broken device prior to its actual use.
2.
The evidence surrounding the broken trip device strongly supports the theory that it was improperly packaged and handled, and was probably damaged sometime between leaving the vendor's plant and installation by PSE&G.
Based on this evidence and tests performed by Franklin Research Center and the vendor on the broken and unbroken devices, there is no reason to suggest that there is an inherent design or manufacturing deficiency m the tab lever.
APPENDIX II
2 BETA is of the further opinion that this incident provides additional support for the need for PSE&G to accomplish a number of the previously identified long term fixes. From PSE&G's viewpoint, it would have been beneficial had this broken device been discovered prior to installation. This would have been the case had there been a requirement for a PSE&G Quality Control inspection upon receipt at the site even though PSE&G Q A inspectors witnessed the testing of these devices at the vendor's plant prior to shipment.
At the present, commercial grade devices such as this, are inspected by PSE&G warehousemen for obvious shipping damage, counting and proper shipping papers only, it is our understanding that PSE&G procedures are being rewritten to accomplish this change.
Notwithstanding the above comment, BETA continues to support fully the findings and recommendations contained in our April 14, 1983 letter to you.
Sincerely, W. Wegne Associate k
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