ML20057E583

Summary of Operating Reactors Events Meeting 93-33 on 930901

ML20057E583
Person / Time
Site:	Crystal River, Big Rock Point  File:Consumers Energy icon.png
Issue date:	09/10/1993
From:	Chaffee A Office of Nuclear Reactor Regulation
To:	Grimes B Office of Nuclear Reactor Regulation
References
OREM-93-033, OREM-93-33, NUDOCS 9310120318
Download: ML20057E583 (17)

Text

September 10, 1993 MEMORANDUM FOR:

Brian K. Grimes, Director Division of Operating Reactor Support FROM:

Alfred E.

Chaffee, Chief Events Assessment Branch Division of Operating Reactor Support

SUBJECT:

OPERATING REACTORS EVENTS BRIEFING SEPTEMBER 1, 1993 - BRIEFING 93-33 On September 1,

1993, we conducted an Operating Reactors Events Briefing (93-33) to inform senior managers from offices of the l

Chairman, EDO, NRR, ACRS, SECY, AEOD, RES, OE, and regional offices of selected events that occurred since our last briefing i

on August 25, 1993. lists the attendees. presents the significant elements of the discussed events.

contains reactor scram statistics for the week ending i

August 29, 1993.

No significant events were identified for input into the NRC Performance Indicator Program.

[ original signed by Robert L. Dennig for]

Alfred E.

Chaffee, Chief Events Assessment Branch Division of Operating Reactor Support

Enclosures:

As stated DISTRIBUTION:

Central Files cc w/ enclosures:

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H. Berkow (PDII-2)

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Calvo, NRR (14A4)

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J. Roe, NRR (13E4)

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Rubin, AEOD (MN-5219) l M.

Harper, AEOD (MN-9112) j G.

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Bates, SECY (16G15) i T.

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E. Merschorf, Region II S.

Vias, Region II J.

Martin, Region III E.

Greenman, Region III J.

Milhoan, Region IV B.

Beach, Region IV B.

Faulkenberry, Region V K.

Perkins, Region V bec:

Mr. Sam Newton, Manager Events Analysis Department Institute of Nuclear Power Operations 700 Galleria Parkway Atlanta, GA 30339-5957 l

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September 10, 1993 MEMORANDUM FOR:

Brian K.

Grimes, Director Division of Operating Reactor Support FROM:

Alfred E.

Chaffee, Chief Events Assessment Branch Division of Operating Reactor Support

SUBJECT:

OPERATING REACTORS EVENTS BRIEFING SEPTEMBER 1, 1993 - BRIEFING 93-33 On September 1, 1993, we conducted an Operating Reactors Events Briefing (93-33) to inform senior managers from offices of the Chairman, EDO, NRR, ACRS, SECY, AEOD, RES, OE, and regional offices of selected events that occurred since our last briefing on August 25, 1993. lists the attendees.

1 presents the significant elements of the discussed events. contains reactor scram statistics for the week ending August 29, 1993.

No significant events were identified for input into the NRC Performance Indicator Program.

O I

p Nf Alfred E.

Chaffee.

Events Assessment B anch Division of Operating Reactor Support

Enclosures:

As stated cc w/ enclosures:

See next page

~..

ENCLOSURE 1 LIST OF ATTENDEES OPERATING REACTORS EVENTS FULL BRIEFING (93-33)

SEPTEMBER 1, 1993 i

i NAME OFFICE NAME OFFICE i

B.

GRIMES NRR B.

BOGER NRR A.

CHAFFEE NRR F. MIRAGLIA NRR D.

SKEEN NRR L.

OLSHAN NRR l

E.

BENNER NRR W.

DEAN NRR j

K.

GRAY NRR K.

SHEMBARGER OCM/IS i

I R.

DENNIG NRR A.

RAMEY-SMITH OEDO f

E. GOODWIN NRR A.

GODY, JR.

OEDO D.

DESAULNIERS NRR W.

TROSKOSKI OE T.

YAMADA NRR K.

HART SECY j

H.

BERKOW NRR W.

MINNERS RES l

R.

DEPRIEST NRR J.

MATHIS ACRS l

H.

SILVER NRR V.

BENAROYA AEOD

?

I I

i TELEPHONE ATTENDANCE I

(AT ROLL CALL)

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i i

Reaions Resident Inspectors Region I R. Leemon (Big Rock Point) i Region II P.

Holmes-Ray (Crystal River)

Region III Region IV l

Region V i

i IIT/AIT Team Leaders Misc.

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ENCLOSURE 2 I

OPERATING REACTORS EVENTS BRIEFING 93-33 LOCATION:

10 B11, WHITE FLINT WEDNESDAY, SEPTEMBER 1, 1993, 11:00 A.M.

BIG ROCK POINT SAFETY RELIEF VALVE LIFTED DURING PRIMARY SYSTEM HYDR 0 CRYSTAL RIVER, UNIT 3 PARTIAL LOSS OF 0FFSITE POWER EVENTS PRESENTED BY:

EVENTS ASSESSMENT BRANCH DIVISION OF OPERATING REACTOR SUPPORT, NRR u

~

t 93-33 BIG ROCK POINT SAFETY RELIEF VALVE LIFTED DURING PRIMARY SYSTEM HYDR 0 AUGUST 24, 1993 PROBLEM A SAFETY RELIEF VALVE LIFTED (SRV) DURING THE HYDR 0 STATIC PRESSURE TEST OF THE REACTOR COOLANT SYSTEM.

CAUSE THE HYDR 0 PUMP OVERPRESSURIZED THE SYSTEM WHEN A PLANT EQUIPMENT OPERATOR, STATIONED IN CONTAINMENT, LEFT HIS POST AT THE HYDRO PUMP, AT THE REQUEST OF THE SHIFT SUPERVISOR, TO LOOK FOR LEAKS IN THE CONTROL R0D DRIVE SYSTEM.

_ SAFETY SIGNIFICANCE UNNECESSARY CHALLENGE TO THE PLANT WHEN SRV LIFTED.

DISCUSSION o

INITIAL PRIMARY SYSTEM PRESSURE AND TEMPERATURE WERE STEADY AT 1490 PSIG AND 270 *F IN SUPPORT OF THE HYDROSTATIC PRESSURE TEST.

o AN EQUIPMENT OPERATOR (E0) WAS STATIONED AT THE HYDR 0 PUMP INSIDE CONTAINMENT TO PROVIDE PRESSURE CONTROL.

TWO WAY RADIOS WERE BEING USED FOR COMMUNICATION BETWEEN THE CONTROL ROOM AND THE HYDR 0 PUMP.

CONTACT:

D. SKEEN, NRR/0EAB AIT: NO

REFERENCE:

MORNING REPORT DATED SIGEVENT: TBD 08/24/93

BIG ROCK POINT 93-33 o

THE SHIFT SUPERVISOR WAS INSIDE CONTAINMENT, WALKING D0WN SYSTEMS, AND ASKED THE E0 TO CHECK FOR LEAKS IN THE CONTROL R0D DRIVE SYSTEM.

o THE E0 LEFT THE HYDR 0 PUMP AREA TO WALK DOWN THE CRD ROOM, LEAVING HIS RADIO AT THE HYDR 0 PUMP.

o THE CONTROL ROOM OPERATOR (CRO) NOTICED A PRESSURE INCREASE AND CALLED THE EQUIPMENT OPERATOR TO REDUCE HYDR 0 PUMP FLOW.

GETTING NO RESPONSE, THE CR0 TRIED THE PLANT PAGING SYSTEM, BUT STILL GOT NO RESPONSE.

o THE SHIFT SUPERVISOR, HEARING THE CR0 ATTEMPTING TO RAISE THE E0 ON THE PLANT PAGING SYSTEM, RETURNED TO THE HYDR 0 PUMP AND REDUCED SYSTEM PRESSURE TO 1370 PSIG.

o REACTOR PRESSURE REACHED 1570 PSIG DURING THE PRESSURE INCREASE AND LIFTED ONE OF THE SRVs AND BLEW 4 RUPTURE DISCS.

o PRIMARY SYSTEM PRESSURE WAS RETURNED TO 1500 PSIG AND THE HYDR 0 WAS COMPLETED ABOUT 3.5 HOURS AFTER THE j

EVENT.

FOLLOWUP e

THE LICENSEE REPLACED THE BLOWN RUPTURE DISCS AND WILL MONITOR THE SRVs DURING STARTUP AT THE END OF THE REFUEL OUTAGE.

THE RESIDENT INSPECTOR WILL PERFORM A SPECIAL INSPECTION IN THE AREA 0F HUMAN PERFORMANCE WITH HELP FROM NRR HUMAN FACTORS ASSESSMENT BRANCH.

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FIGURE 2 - BIG ROCK POINT RELIEF VALVES AND RUPTURE DISCS

i 93-33 CRYSTAL RIVER, UNIT 3 PARTIAL LOSS OF 0FFSITE POWER EVENTS MARCH 11 - APRIL 8, 1993 PROBLEM THE UllIT EXPERIENCED SEVEN PARTIAL LOSS OF 0FFSITE POWER OCCURRENCES WHILE SHUTDOWN.

CAUSE FOUR EVENTS INVOLVED PROCEDURAL WEAKNESSES AND THE REMAINING THREE EVENTS WERE A RESULT OF ADVERSE WEATHER CONDITIONS OVER THE WEEKEND OF MARCH 13, 1993.

SAFETY SIGNIFICANCE THE EVENTS IN AGGREGATE REPRESENT A WEAKNESS IN THE LICENSEE'S MANAGEMENT OF 0FFSITE POWER SOURCES.

TWO j

EVENTS RESULTED IN TEMPORARY LOSSES OF SHUTDOWN C0OLING.

DISCUSSION MARCH 11, 1993:

)

e ONE 230KV TIE BREAKER TO STARTUP TRANSFORMER WAS INADVERTENTLY TRIPPED DURING MAINTEllANCE ACTIVITIES.

• ENGINEERED SAFETY FEATURES (ESF) BUSES ALIGNED TO 500KV SWITCHYARD THROUGHOUT EVENT.

MARCH 13, 1993:

• SEVERE WEATHER CAUSED STARTUP TRANSFORMER AND OllE OF TWO 500KV BACKFEEDS TO TRIP.

CONTACT:

E. BENNER, NRR/ DORS AIT: N0 i

REFERENCE:

10 CFR 50.72 #25273 SIGEVENT: YES

CRYSTAL RIVER, UNIT 3 93-33 e "B" EMERGENCY DIESEL GENERATOR (EDG) AND ESF BUS OUT OF SERVICE FOR MAINTENANCE.

e "A" ESF BUS MANUALLY ALIGNED TO EDG AT ONSET OF SEVERE WEATHER CONDITIONS.

e "A" ESF BUS REMAINED POWERED THROUGHOUT EVENT.

e 230KV SWITCHYARD REMAINED AVAILABLE THROUGHOUT EVENT.

MARCH 17, 1993:

e LIGHT RAIN COMBINES WITH SALT DEPOSITED IN SWITCHYARD DURING MARCH 13 STORM; CAUSES LOSS OF 230KV SWITCHYARD WHICH HAD NOT BEEN WASHED SUBSEQUENT TO STORM.

e 500KV BACKFEED AND STARTUP TRANSFORMER AVAILABLE, BUT HEAVY RAIN RAISED QUESTIONS ABOUT RELIABILITY.

e "B" EDG AND ESF BUS OUT OF SERVICE FOR MAINTENANCE.

e "A" ESF BUS ALIGNED TO EDG PRIOR TO LOSS OF 230KV SWITCHYARD.

e "A" ESF BUS REMAINED POWERED THROUGHOUT EVENT.

MARCH 25, 1993:

e RELAY TECHNICIAN PLACES TEST INSTRUMENT LEADS ON WRONG TERMINALS:

"B" 230KV BUS TRIPS.

e ESF BUSSES POWERED FROM 500KV SWITCHYARD THROUGHOUT EVENT.

d

CRYSTAL RIVER, UNIT 3 93-33 MARCH 29, 1993:

• CONTROL POWER CABLE IN 500KV SWITCHYARD FAILS DUE TO PREVIOUSLY UNDETECTED CABLE DAMAGE AND SUBMERGENCE OF CABLE:

500KV BACKFEED POWERING ESF BUSSES LOST.

e BOTH EDGs START AND ENERGIZE RESPECTIVE ESF BUSSES.

• SHUTD0Wil COOLING UNAVAILABLE FOR FIVE MINUTES UNTIL OPERATORS MANUALLY START RESIDUAL HEAT REMOVAL PUMPS.

e TEMPERATURE INCREASED 14 *F AT CENTER OF CORE.

e 230KV SWITCHYARD REMAINED AVAILABLE THROUGHOUT EVENT.

APRIL 8, 1993:

e "B" 230KV BUS TRIPS DUE TO ERRORS IN FUNCTIONAL TESTING.

• ESF BUSSES POWERED FROM 500KV SWITCHYARD THROUGHOUT EVENT.

APRIL 8, 1993:

e 500KV SUPPLY BREAKERS OPEN DUE TO INADEQUATE MAINTENANCE ON CONTROL POWER SYSTEM.

e "A" ESF BUS OUT OF SERVICE FOR INSTALLATION OF NEW TRANSFORMER.

e "B" EDG STARTS AND ENERGIZES "B" ESF BUS.

e SHUTDOWN C0OLING UNAVAILABLE FOR THREE MINUTES UNTIL OPERATORS MANUALLY START RESIDUAL HEAT REMOVAL PUMP.

CRYSTAL RIVER, UNIT 3 93-33 e TEMPERATURE INCREASED 4.5 *F.

FOLLOWUP e TWO SOURCES OF POWER REMAINED AVAILABLE TO ESF BUSSES FOR EACH EVENT.

i e REGION II INITIATED A REACTIVE INSPECTION AS A RESULT OF THE EVENTS:

VIOLATION ISSUED BASED ON INADEQUATE PROCEDURES.

e LICENSEE MET WITH NRR AND REGION II IN JUNE TO DISCUSS EVENTS, ADEQUACY OF 0FFSITE POWER, AND CORRECTIVE ACTIONS.

CORRECTIVE ACTIONS INCLUDE:

- IMPROVE NUCLEAR STAFF KNOWLEDGE OF SWITCHYARD

- IMPROVE INTERFACE PROCEDURES BETWEEN CRYSTAL RIVER 3 AND OTHER FLORIDA POWER CORPORATION PERSONNEL

- CONTROL SWITCHYARD WORK ON SHUTDOWN COOLING POWER SUPPLIES DURING OUTAGES

- REVIEW GUIDELINES FOR PROCEDURE ADEQUACY

- REMOVE SALT FROM INSULATORS IN A TIMELY FASHION

- SPECIFIC ACTIONS FOR EACH EVENT e THE BASIS FOR SIGNIFICANT EVENT CLASSIFICATION IS PROGRAMMATIC WEAKNESSES IN THE LICENSEE'S MANAGEMENT OF PLANTS; THE MULTIPLE PARTIAL LOSS OF 0FFSITE POWER 4

EVENTS IN AGGREGATE INDICATE A WEAKNESS IN CONTROL 0F SWITCHYARD ACTIVITIES DURING COLD SHUTDOWN.

o RII/NRR DEVELOPING INFORMATION NOTICE, " DEGRADATION OF 0FFSITE POWER SOURCE FROM SALT BUILDUP."

ENCLOSURE 3 REACTOR SCRAM i

Reporting Period: 08/23/93 to 08/29/93 YTD TTD ABOVE BELOW YTD E

PL8ht & LNIT POWER ILP[

CAUSE COMPlfCAff0NS M

M Ygg 08/23/93 OCONEE 1 100 SA Maintenance Error WO 1

1 2

08/23/93 SUERY 2 97

$A Equipment f ailure NO 3

0 3

08/25/93 DCohEE 2 100 SA operating Error WO 1

1 2

05/27/93 COOK 2 90 SA Equipment Failure No 2

0 2

1 05/27/93 SURRY 2 97 sA Equipnent Failure WO 4

0 4

hete: Year to Date (YTD) Totals Include Events Within The Calendar Year Indicated By The End Date of the specified Reporting Feriod E15-10 Fage:1 09/01/93

i

-1 COMPAR150W OF WEEKLY SCRAM $7AtlSTICS WITM INDUSTRY AVERAGES 1

PER100 ENDlhG 1

08/29/93 WUMBER 1993 1992 1991*

1990*

W89*

j i

0F WEEKLY WEEKLY WEEKLY WEEKLY WEEKLY i

l SCRAM CAUS[

$ CRAMS AVERAGE AVERAGE A\\TRAGE AVERAGE AVEkAGE EYTD)

POWER GREATER THAN OR EQUAL TO 15%

I i

EQUIPMENT FAILURE

• 3 1.9 2.6 2.9 3.4 3.1 1

DESIGN / ins 1ALLAT10% ERROR

• 0 0.1 OPERAT1WG ERROR

• 1 0.3 0.2 0.6 0.5 1.0 MAlhTEhANCE ERROR

• 1 0.6 0.4 i

Ex1ERkAL*

0 0.1 OTHER*

0 0.0 0.2 0.1 1

l l

I subtetal 5

3.0 3.4 3.5 3.9 4.2 POWER LL45 fr.AW 15%

EQUIPMENT F AILUTIE*

O 0.3 0.4 0.3 0.4 0.3 DESIGh/1kS1ALLATIO* ERROR

• 0 0.0 OFER AT!bG ERROR

• 0 0.2 0.1 0.2 0.1 0.3 MAlkTEhAAEE ERROR

• 0 0.0 0.1 EXTERNAL

• 0 0.0 OTNER*

0 0.0 0.1 subtetet 0

0.5 0.7 0.5 0.5 0.6

)

TCTAL 5

3.5 4.1 4.0 4.4 4.8 1993 1992 1991 1990 1989 ko. OF WEEKLY WEEKLY WEEKLY WEEKLY WEEKLY SC8 W YYPE SCRAMS AVERAGE AVE R AGE AVERAGE AVERAGE AVE R AGE (YTD)

TOT AL AUTCMATIC SCRAMS 5

2.6 3.1 3.3 3.2 3.9 TOTAL MANUAL SCRAMS 0

1.0 1.0 0.7 1.2 0.9 TOTALS MAY DIFFER SECAUSE OF RDUND!hG OFF

• Cetailed breakdoe not in database for 1991 and earlier

- EXTE8EAL casse included in EQUIPMENT F AILUkE

- MAlwithAkCE EPROR and DE51Gh/1W5f ALLATION ERROR causes included in DrERATihG ERROR

- OTHER casse included in EQUIPMENT FAILURE 1991 anc; 1990 i

115-14 Page: 1 09/01/93 4

. =..

_. _ ~.

4 a

l NOTES 1.

PLANT SPECIFIC DATA. BASED ON INITIAL REVIEW OF 50.72 REPORTS FOR THE j

WEEK OF INTEREST.

PERIOD IS MIDNIGHT SUNDAY THROUGH MIDNIGHT SUNDAY.

1 SCRAMS ARE DEFINED AS REACTOR PROTECTIVE ACTUATIONS WHICH RESULT IN ROD MOTION, AND EXCLUDE PLANNED TESTS OR SCRAMS AS PART OF PLANNED SHUTDOWN IN ACCORDANCE WITH A PLANT PROCEDURE.

THERE ARE 111 REACTORS HOLDING AN OPERATING LICENSE.

2.

PERSONELL RELATED PROBLEMS INCLUDE HUMAN ERROR, PROCEDURAL DEFICIENCIES, AND MANUAL STEAM GENERATOR LEVEL CONTROL PROBLEMS.

3.

COMPLICATIONS: RECOVERY COMPLICATED BY EQUIPMENT FAILURES OR PERSONNEL ERRORS UNRELATED TO CAUSE OF SCRAM.

4.

"OTHER" INCLUDES AUTOMATIC SCRAMS ATTRIBUTED TO ENVIRONMENTAL CAUSES (LIGHTNING), SYSTEM DESIGN, OR UNKNOWN CAUSE.

OEAB SCRAM DATA Manual and Automatic Scrams for 1987 ------------------ 435 Manual and Automatic Scrams for 1988 ------------------ 291 Manual and Automatic Scrams for 1989 ------------------ 252 Manual and Automatic Scrams for 1990 ------------------ 226 Manual and Automatic Scrams for 1991 ------------------ 206 Manual and Automatic Scrams for 1992 ------------------ 212 i

Manual and Automatic Scrams for 1993 --(YTD 08/29/93)-- 123 i

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i 1

.