ML20024B295
| ML20024B295 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 06/11/1979 |
| From: | Kosiba R BABCOCK & WILCOX CO. |
| To: | Macmillan J BABCOCK & WILCOX CO. |
| References | |
| TASK-01, TASK-06, TASK-07, TASK-08, TASK-1, TASK-11, TASK-6, TASK-7, TASK-8, TASK-GB GPU-2426, NUDOCS 8307080295 | |
| Download: ML20024B295 (4) | |
Text
{{#Wiki_filter:____________________________ _ ounua 1 .f. ~~ m 7 t.N 4 c T'iE BABCOCX.i WILCOX COMPANY DI POWER' GENERATION GROUP Idl To l J. H. Mac.Millan, Vice President __ p ),N Nuclear Power Generation Division
- W.
m L E. Kosiba, Manager \\ Customer Service Depart =ent. NPCD (3469) ses 663.s I Cust. File No. or Raf. f 0 N P '*
- t n a p 33 THI-2 Top Ten Lessons % g ',
June 11, 1979 l m. M P 0 J.***, C ~" { 4 1. Our total product (hardware, sof tware and services) was not adequate to - ID l. preveat a long-duration less of control of the plant and most severe da=an { to the core. Ve need to make changes in our total product - hardware, service, instutional, and sof tware in order to co=pete with those who have E l not had a coc: parable accident. ' j <^ W.,s W. h W i-- Q h 2. The training of operators was not sufficient to assure proper =anag nenr of the plant. L 3. Our support to the operators during the incident was not sufficaintly effective to converge to controlled conditions. Corrective action needed in if comunication and organization. Note - Our telephone off hours set-up 'was D an irritant and contributed delay / confusion. D'* df4y T,.7 j', -
- i 4.
The education and training of our peopic (site and ho=e office) was not Y 8-7 ., sufficient and needs to be upgraded to =anage real ti=a incident support. ) C The design of the contral roon de=onstinted its iradequacy by co(ntribu ing ) L %d 4 W ~ .5. t-to the confusion of the operators. By design 1 include having the needed L instru=ents, no_t, having excess unneeded instru=ents to distract operators, k t having proper contrast of instru=ents important to safety of the plant, allowing for co1=nunication, 'etc. 6. The design of the plant was not adequately co-icated to operations. I (Operations includes B&W people, customer and even NRC). We need a current { and comprehensive docu=ent that coc=unicates how the plant responds to upsets S and casualties for use by plant operators, service personnel of B&W and also 1 to assure consistent understanding a=cag design engineer disciplinas - h, safety / controls analysis, syste=s engineers (I&C/ fluid) and con:ponents. l 7. Our knowledge and control / influence of BCP systens was not adequate to provide C for achieving the reliable / predictable perfor=anca of our 555 needed to be f competitive. j g ? i ~ t p. EE ? 9 ~ ~ ~' _ ,___.7 m, m- =._.. O - 8307000295 790611 PDR ADOCK 05000289 i i: P HOL _ _ _ _ _ _ ______ _ ____ _______r_ ____ _ _____ _ __ ________ _ _____ _ ___ _
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-7~ J.me 11,1919 1 M/ !l d M 8. Our use of operating experience was not adequate as denocstrated by the failure ( to perceive the warnings i=plicit in Septenber 1977 Davis-3 esse depressurisatica (and earlier SP.'.!D) and take strong actions pec=ptly to. prevent occurrence psu. W m)k of more severe incidents. 9. Avaialbility of design data for operating plants (NSS and BOP) is not sufficiently L12 accc.ssible, assured current and usable to f acilitate real time support. '/[7"6
- 10. The syste=s engineer function (fluid,and I&C) was erratic in developing f
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procedures in response to TMI-2. On successive shifts people filled this 7 Iunction ren varied orgssizational units - IPM, Syste=s & Equipcent, CSD, R&D - with the result that procedures, prepared varied or vere inconsistent in f r for=at, content, standard. (. 6 y-G_ III:vp 7 r-C e t' w r; L 4 7,. s
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~ ~ - - - - - "T ~ T= -... ~:: :'~~ ~ e s %h. THE BABC0CX & WILCOX COMPANY ,rg POWER' GENERATION GPOUP g To l J.H. MacMILLM. VICE PRE 510ENT NUCLEAR PC'.iER GENERATION DIVISION N. AJ. Free -{. R.M. BALL. PMGER PR000CT CEVELOPMENT jos us.4 File No. f Cust. or Ref. g((G -] lil !
- Suoj, Date l
T6P10LESSONSLEARNED JUNE 8, 1979 ,i g e u. t h. Occurrence Lesson 6 I b, 1. Operators did not diagnose 1. Plant operators need greater training F situation correctly and had an in of f-nor s1. multi-failure conditions. s incorrect " process image". Operators should know hcw to obtain f expert help, p,- 2. No direct indication of core 2. Unaciguous indication should be presented E cooling was available and too to operators.on present core ecoling with many alarms required attention. alternate methods for future cooling. h'_, 3. Radiation-bearing air and water 3. Pipes or vents carrying radiation out of [, left the containment. containment should be isolate t high i pA
- 7. z level indication. NI"k o " &,
(J toJ 4. Radiation release frcm site was 4. Increased number of monitors and training not monitored accurately enough. of interpreters. 5. liydrogen bubble was not easily 5. Should be able to vent gases from' primary vented or controlled. system high points and reccebine within d a contain.nent. 6. Heat removal from highly 6. Alternite decay heat. sinks should be ' radioactive primary coo 14nt available to work at operating pr'essur's [. depended on operation of steam and with radioactive coolants. y 7 generators. 7. Co.cunications among operations. 7. Utilities should establish pre-planned h management technical support communication channels and have equiprent h and the public was intermittent installed to link all parties. [ y, and faulty. 8. Indication of open reitef valve 8. Every opening which could rem 2ve or insert 1 water from the primary system should be L was not adequate, conitored for flaw. Review previous F occurrences. p [ r ~ L ...-g -, s O wew%. 4' 'I L-
e. n--- =.. 7 :w,7 g .ci 'i tC1 J.H. MacMILLAM L. R.M. BALL 'IO TOP 10 LESSCNS LEARNED h-JUNE 8. 1979 PAGE 2 " ~{ 5 .t ....t 4 9. Ceeponents and sensors were 9. Accident conditions should not destroy B3 i subject to environ: ental vital indications. Redundancy and i extremes and sera failed. diversity should be increased.
- 10. The utility was lucky to have
- 10. All plants should have continuous flight 7
the reactimeter and the thermo-recorder conitoring and all inceres should ? couples connected. be connected with rnaximum range. e I b-e F. i N t e Y k L r.: W I I RNB/dsv B cri D.H. Roy i' k,- R.E. Kostba J.C. Deddens [ D.W. Berger ' i k g t (* e k L i.- k_. L 1 1 I k P t n 9 F w' ~ ' ~ ' ~ 'T \\. '[" ..- _L;C s ;._ t -}}