ML20058K130

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Summary of Operating Reactors Events Meeting 93-44 on 931124
ML20058K130
Person / Time
Site: Robinson, Fort Calhoun  Duke Energy icon.png
Issue date: 11/29/1993
From: Chaffee A
Office of Nuclear Reactor Regulation
To: Grimes B
Office of Nuclear Reactor Regulation
References
OREM-93-044, OREM-93-44, NUDOCS 9312140425
Download: ML20058K130 (15)


Text

. . _ _ - . .- .

November 29, 1993 l MEMORANDUM FOR: Brian K. Grimes, Director i Division of Operating Reactor Support l FROM: Alfred E. Chaffee, Chief Events Assessment Branch Division of Operating Reactor Support l

SUBJECT:

OPERATING REACTORS EVENTS BRIEFING ,

NOVEMBER 24, 1993 - BRIEFING 93-44 On November 24, 1993, we conducted an Operating Reactors Events Briefing (93-44) to inform senior managers from offices of the  !

Chairman, ACRS, NRR, AEOD, and regional offices of selected .

events that occurred since our last briefing on November 17, 1993. Enclosure 1 lists the attendees. Enclosure 2 presents the significant elements of the discussed events.

Enclosure 3 contains reactor scram statistics for the week ending [

November 21, 1993. No significant events were identified for input into the NRC Performance Indicator Program.  ;

original signed by E. Goodwin for Alfred E. Chaffee, Chief  !

Events Assessment Branch i Division of Operating  !

Reactor Support  ;

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Enclosures:

As stated DISTRIBUTION:

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T. Murley, NRR (12G18) B. Mozafari (PDII-1)

F. Miraglia, NRR (12G18) S. Bajwa (PDII-1)

F. .Gillespie, NRR (12G18) S. Bloom (PDIV-1)

J. Callan, NRR (12G18) W. Beckner (PDIV-1)

S. Varga, NRR (14E4)

J. Calvo, NRR (14A4)

G. Lainas, NRR (14H3)

J. Roe, NRR (13E4)

J. Zwolinski, NRR (13H24)

E. Adensam, NRR (13E4)

W. Russell, NRR (12G18)

J. Wiggins, NRR (7D26)

A. Thadani, NRR (8E2)

S. Rosenberg, NRR (10E4)

C. Rossi, NRR (9A2)

B. Boger, NRR (10H3)

F. Congel, NRR (10E2)

D. Crutchfield, NRR (11H21)

W. Travers, NRR (11B19)

D. Coe, ACRS (P-315)

E. Jordan, AEOD (MN-3701)

G. Holahan, AEOD (MN-9112)

L. Spessard, AEOD (MN-3701)

K. Brockman, AEOD (MN-3206)

S. Rubin, AEOD (MN-5219)

M. Harper, AEOD (MN-9112)

G. Grant, EDO (17G21)

R. Newlin, GPA (2G5)

E. Beckjord, RES (NLS-007)

A. Bates, SECY (16G15)

T. Martin, Region I W. Kane, Region I R. Cooper, Region I S. Ebneter, Region II E. Merschoff, Region II S. Vias, Region II J. Martin, Region III E. Greennan, 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

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%,'%< s f[ WASHINGTON, D.C. 20066-0001 November 29, 1993

  • ...* l 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 NOVEMBER 24, 1993 - BRIEFING 93-44 On November 24, 1993, we conducted an Operating Reactors Events Briefing (93-44) to inform senior managers from offices of the Chairman, ACRS, NRR, AEOD, and regional offices of selected events that occurred since our last briefing on November 17, 1993. Enclosure 1 lists the attendees. Enclosure 2 presents the significant elements of the discussed events.

Enclosure 3 contains reactor scram statistics for the week ending )

November 21, 1993. No significant events were identified for input into the NRC Performance Indicator Program. ]

b N Alfred E. Chaffee, Chief .

Events Assessment Branch I Division of Operating l Reactor Support

Enclosures:

As stated ,

I cc w/ enclosures:

See next page i

i 1

ENCLOSURE 1 LIST OF ATTENDEES OPERATING REACTORS EVENTS FULL BRIEFING (93-44)

NOVEMBER 24, 1993 NAME OFFICE NAME OFFICE l

E. GOODWIN NRR M. VIRGILIO NRR N. FIELDS NRR M. SHANNON NRR T. KOSHY NRR G. CWALINA NRR 1 K. GRAY NRR H. RICHINGS NRR S. BAJWA NRR V. BENAROYA AEOD J. IBARRA OCM S. WEISS NRR D. THATCHER NRR C. E. ROSSI NRR S. BLOOM NRR B. K. GRIMES NRR T. YAMADA NRR B. MOZAFARI NRR W. BECKNER NRR S. WU NRR E. MARINOS NRR J. ROE NRR  ;

T. ANDREWS AEOD G. MARCUS NRR l W. HAASS NRR W. ROGERS NRR D. COE ACRS V. HODGE NRR M. MARKLEY NRR D. GAMBERONI NRR j S. MAZUMDAR NRR G. ZECH NRR l TELEPHONE ATTENDANCE (AT ROLL CALL)

Recions Pesident Inspectors Region II Region III Region IV IIT/AIT Team Leaders Misc.

T. Peebles (Robinson)

T. Stetka (Fort Calhoun)

- Enclosure 2 i

OPERATING REACTORS EVENTS BRIEFING 93-44  ;

LOCATION: 10 Bil, WHITE FLINT WEDNESDAY, NOVEMBER 24, 1993 11:00 A.M.

i i

H. B. ROBINSON, UNIT 2 FUEL FABRICATION AND CORE  :

PHYSICS DEFICIENCIES (AIT) j i

4  :

FORT CALHOUN R0D CONTROL SYSTEM ,

DEFICIENCIES -(AIT) l l

l PRESENTED BY: EVENTS ASSESSMENT BRANCH .

DIVISION OF OPERATING REACTOR 1 SUPPORT, NRR l

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6 l

wy*-:-- .y-- -, --y. + , - .,4 - w a s r e--->- w,

93-44 H. B. ROBINSON, UNIT 2 FUEL FABRICATION AND CORE PHYSICS DEFICIENCIES NOVEMBER 18, 1993 PROBLEM:

AS-LOADED GAD 0LINIUM PIN LOCATIONS IN SIX FUEL ASSEMBLIES WERE IN INCORRECT QUADRANTS OF THE ASSEMBLIES; ALSO, OTHER PHYSICS & FUEL HANDLING PROBLEMS IDENTIFIED.

.CAUSE:

MANUFACTURING, TECHNICAL AND PROCEDURAL ERROR.

SAFETY SIGNIFICANCE:-

P0TENTIAL FOR FUEL DAMAGE AS A RESULT OF EITHER INCORRECT CONFIGURATION OF FUEL ASSEMBLY OR OF INCORRECT POWER RANGE CALIBRATION.

l DESCRIPTION OF EVENTS-e ON NOVEMBER 16, 1993, DURING ROUTINE FLUX MAPPING AT 30 l PERCENT POWER WHILE STARTING UP FROM A REFUELING OUTAGE, AN UNEXPECTED FLUX DISTRIBUTION WAS DETECTED.

e THE LICENSEE DETERMINED THAT THREE GAD 0LINIUM PINS IN EACH OF SIX ASYMMETRICALLY POIS0NED FUEL ASSEMBLIES MANUFACTURED BY THE SIEMENS POWER CORPORATION OF RICHLAND, WASHINGTON, WERE LOCATED IN INCORRECT QUADRANTS. THE LOCATIONS OF THE ASSEMBLIES AND OF THE PINS ARE SHOWN ON PROPRIETARY DIAGRAMS. THE POSSIBILITY OF OTHER ERRORS IS BEING EXAMINED.

CONTACTS: N. FIELDS, NRR/ DORS /EAB AIT: YES T. PEEBLES, AIT TEAM LEADER SIGEVENT: TBD

REFERENCES:

10 CFR 50.72 #26385, #26390, l

  1. 26391, AND PN0-II-93-064 1

H.B. ROBINSON, 93-44 UNIT 2 3 THE SIX ASSEMBLIES WERE PART OF A TOTAL OF 56 FUEL ASSEMBLIES LOADED DURING THE LAST REFUELING OUTAGE.

THE CONFIGURATION ANOMALY APPARENTLY RESULTED FROM DESIGN AND MANUFACTURING PROBLEMS.

o THE GAD 0LINIUM PINS ARE USED AS FIXED, DISCRETE BURNABLE POIS0NS, THE MIS-POSITIONING 0F WHlCH COULD RESULT IN THERMAL OR SAFETY LIMIT VIOLATIONS WHICH MAY NOT BE DETECTABLE BY EXCORE POWER MONITORING SYSTEMS.

o SIGNIFICANTLY EXCEEDING THERMAL OR SAFETY LIMITS COULD LEAD TO FUEL DAMAGE AND THE RELEASE OF FISSION PRODUCTS INTO THE REACTOR COOLANT SYSTEM.

o ON NOVEMBER 17, 1993, AFTER HAVING PLACED THE REACTOR i IN HOT SHUTDOWN, THE LICENSEE AND SIEMENS REPRESENTATIVES DETERMINED THAT WHILE OPERATING AT 30 PERCENT POWER ON HOVEMBER 14 TO NOVEMBER 17, 1993, THE l

UNIT MAY HAVE EXCEEDED THE HOT CHANNEL FACTOR BY APPR0XIMATELY 9 PERCENT OF THE CORE OPERATING LIMIT REPORT. l l

o NO FUEL DAMAGE HAS YET BEEN DETECTED. l i

e OTHER PROBLEMS WEPE IDENTIFIED DURING THE STARTUP:

  • MISCALIBRATED POWER RANGE NUCLEAR INSTRUMENTATION CHANNELS WHICH READ 10 PERCENT BELOW ACTUAL POWER. l THIS ERROR, FORTUITOUSLY, DID NOT CONTRIBUTE TO l l

EXCEEDING CORE LIMITS AS FLUX MAP WAS DONE AT INDICATED 20 PERCENT RATHER THAN 30 PERCENT AS PLANNED.

~ i H.B. ROBINSON, 93-44 l

.' . UNIT 2  ;

e A-BROKEN FUEL HANDING TOOL WA3 DISCOVERED; THE l i

FAILURE WAS'KNOWN TO SIEMEN'S. CONTRACT REFUELING CREW BUT PLANT DISCOVERED IT ONLY DURING FUEL j HANDLING. -l FOLLOWUP: l o SHUTDOWN WAS INITIATED AND THE LICENSEE ANTICIPATES:A. l MID-DECEMBER RESTART. THE VENDOR / LICENSEE WILL RECONFIGURE THE ASSEMBLIES WITH MISPOSITIONED l GADOLINIUM POISON RODS TO THEIR PROPER POSITIONS. ,

o THE REGION DISPATCHED AN AUGMENTED INSPECTION TEAM TO

. THE SITE ON NOVEMBER 19, 1993 TO EVALUATE THE FACTS-SURROUNDING THE EVENTS AT ROBINSON AND AT SIEMENS.  :

o AN INSPECTION AT SIEMENS, RICHLAND, IS PLANNED AS PART  !

0F AIT. 1 e AN INFORMATION NOTICE WILL BE DRAFTED ON THIS EVENT.

ACTION BRANCH STILL TO BE DETERMINED.

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93-44 FORT CALHOUN R0D CONTROL SYSTEM DEFICIENCIES NOVEMBEP 13, 1993 PROBLEM UNCONTROLLED CONTROL R0D MOVEMENTS DURING CONTROL R0D POSITION INDICATION SYSTEM SURVEILLANCE. -

CAUSE MULTIPLE GROUND FAULTS, WIRING SHORTS, AND LACK OF GROUND FAULT DETECTION IN CONTROL R0D DRIVE SYSTEM.

SAFETY SIGNIFICANCE UNANTICIPATED CHANGES IN REACTIVITY.

BACKGROUND o LICENSEE WAS CONDUCTING A TEST OF THE SECONDARY CONTROL ELEMENT ASSEMBLY POSITION INDICATING SYSTEM (SCEAPIS) .

BEFORE START UP.

e ON NOVEMBER 13, 1993 AT 10:21 P.M., WITH THE R0D MODE SELECTOR SWITCH IN MANUAL INDIVIDUAL POSITION, THE OPERATOR PLACED THE R0D BLOCK SWITCH IN BYPASS AND R0D 30 WAS WITHDRAWN APPR0XIMATELY TWO INCHES FROM THE BOTTOM POSITION.

CONTACT: T. K0 SHY, NRR/ DORS /EAB AIT: YES T. STETKA, AIT TEAM LEADER SIGEVENT: TBD

REFERENCES:

10 CFR 50.72 #26366, AND MORNING REPORT 4-93-0064 l

l FORT CALHOUN- -2 93-44 l o AFTER RELEASING THE ROD BLOCK BOTTOM SWITCH FROM BYPASS, THE-SCEAPIS:WAS RESET TO SIMULATE ALL RODS OUT l (WHICH CLEARED THE ROD BLOCK) AND A " CONTINUOUS ROD l

i MOTION" ALARM CAME ON. THE OPERATOR TURNED SELECTOR i

SWITCH TO 0FF REMOVING CONTROL POWER TO THE DRIVE MECHANISMS AND THE ALARM CLEARED. ALL ROD BOTTOM i LIGHTS REMAINED LIT. l o I&C PERSONNEL WERE CALLED TO IDENTIFY CAUSE OF ALARM, j BUT THEY COULD NOT FIND A CAUSE. l o TO FURTHER TROUBLESHOOT THIS ALARM, AT 10:35 P.M. THE  ;

OPERATOR TOOK THE ROD MODE SELECTOR OUT OF "0FF" T0- l TIME THE " CONTINUOUS ROD MOTION" ALARM (IT SHOULD HAVE l TIMED OUT AT 32 SECONDS) SINCE THEY FELT THAT THE ALARM j

-MAY BE INVALID.

l o  !

32 SECONDS LATER " CONTINUOUS ROD MOTION" ALARM CAME-ON-AND CLEARED. ROD 31 FULL.0UT LIGHT CAME-ON. THE ROD l BOTTOM LIGHT REMAINED ON. ROD WAS VERIFIED TO BE FULLY  !

OUT.

o THE OPERATORS BEGAN MANUALLY DRIVING R0D 31 INTO CORE.

o AT 10 INCHES INTO CORE, OPERATOR STOPPED ROD MOTION TO ACKNOWLEDGE AN UNRELATED ALARM.

o R0D 31 STARTED MOVING OUnlARD WITH R0D CONTROL J0Y STICK IN THE NEUTRAL POSITION. ROD MODE SELECTOR-SWITCH WAS TURNED T0 "0FF" POSITION AND ROD MOTION STOPPED.

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j FORT CALHOUN 93-44 o IN ANOTHER ATTEMPT TO DRIVE ROD 31 IN, THE ROD STARTED OUT. IN THE NEXT ATTEMPT, THE ROD FULLY INSERTED.

J o AFTER VERIFYING THAT ALL RODS ARE FULLY INSERTED, SCRAM j BREAKERS WERE TRIPPED.

o ON NOVEMBER 18, 1993 NON-TRIPPABLE CONTROL ROD 18-CONTINUED TO MOVE INTO THE CORE WHEN THE JOY. STICK WAS l IN THE NEUTRAL POSITION. RIGHT AFTER THIS ROD COMPLETED I IT'S MOVEMENT, THE ROD CONTROL MIMIC LIGHTS ON THE MAIN l CONTROL BOARD WENT OUT. l o AN AIT WAS DISPATCHED TO THE SITE ON NOVEMBER 18, 1993. {

DISCUSSION l o CONTROL R0D DRIVE SYSTEM IS POWERED BY AN. UNGROUNDED-l 120 VAC SYSTEM AND IT WAS NOT EQUIPPED WITH GROUND  !

FAULT DETECTION.  ;

I o A MINIMUM OF TWO GROUND FAULTS ARE NEEDED TO CAUSE A I MALFUNCTION LIKE UNCONTROLLED MOTION. j o DIAGNOSTIC TESTING REVEALED THE FOLLOWING DEFICIENCIES IN THE SYSTEM:  ;

i e JUMPER BETWEEN THE 120VAC AND 28VDC POWER SUPPLIES  !

e R0D 30 MICR0 SWITCH GROUNDED e ROD 31 CIRCUIT GROUNDED BY MOISTURE IN CONNECTOR

FORT CALHOUN 93-44 e ROD 18 HAD A WIRE STRAND SHORT BETWEEN-THE PINS IN IT'S CONNECTOR THEREBY PROVIDING A CONNECTION BETWEEN THE 120'VAC AND THE 48 VDC POWER SUPPLIES.

THIS SHORT, THE INTERLOCK BETWEEN THE IN MOTION AND OUT MOTION CONTACTORS, AND THE OPERATION SEQUENCE OF THE ROD CONTROL JOY STICK AND ROD BOTTOM BYPASS SWITCHES CAUSED THE ERRATIC ROD OPERATION.

  • INCORRECT FUSE IN R0D CONTROL MIMIC LIGHTS POWER-SUPPLY (3 AMP FUSE WAS ' INSTALLED INSTEAD OF 10 AMP FUSE). THIS FUSE FAILURE WAS APPARENTLY NOT CAUSED BY THE R0D 18 SHORT.

o LICENSEE INSTALLED PERMANENT GROUND DETECTION IN ROD CONTROL CIRCUITS. (ALL OTHER CE UNGROUNDED SYSTEMS EXCEPT PALISADES HAVE GROUND DETECTION).

o LICENSEE TESTED ALL THE CONTROL RODS WITH THE GROUND DETECTION SYSTEM IN SERVICE.

o AIT EXITED ON NOVEMBER 22, 1993 WITH A PUBLIC MEETING.

FOLLOW UP o REGION IS MONITORING LICENSEE'S SURVEILLANCE TESTING AND POWER ASCENSION.

o NO INFORMATION NOTICE IS PLANNED.

Enclosure 3 t

REACTOR SCRAM i

  • Reporting Period: 11/15/93 to 11/21/93 YTD YTD ,

ABDVE BELOW YTD PDate COMPLICAt!Ows 113 113 TOTAL pal { PLANT s uni 1 TIPI CAUSE 11/15/93 SUERY 2 95 SA Equipment failure NO 5 0 5 100 SA Equipment Failure WO 3 0 3  ;

11/17/93 CDMAhCHE PEAK 2 F

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l kote: Year 10 Date (f1D) Totals include Events Within The Calendar Vaar Indicated By 1be End Date Of The specified Reporting Period ETS*10 Page:1 11/24/93

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COMPARISDN OF WEEKLY SCRAM STATISTICS WITH INDUSTRY AVERAGES ,

i PER100 ENDING i

11/21/93 NUMBER 1993 1992 1991* 1990* 1989*

OF WEEKLY WEEKLY WEEKLY WEEKLY WEEKLY SERAM CAUSE SCRAMS AVERAGE AVERAGE AVERAGE AVERAGE AVERAGE (YTD)

PD.IER GREATER THAN OR EQUAL .015%

EQUIPMEET FAILURE

  • 2 1.8 2.6 2.9 3.4 3.1 l DESIGN /lkSTALLATION ERROR
  • 0 0.0 - - -- -

OPERAT1hG ERROR

  • 0 0.3 0.2 0.6 0.5 1.0 MAINTENANCE ERROR
  • O 0.5 0.4 - - -

EXTERhAL* O 0.1 - - - -

l OTHER* O 0.0 0.2 - -

0.1 t t

subtotal 2 2.7 3.4 3.5 3.9 4.2 I h

POWER LESS THAN 15%

EDUlFMEh1 FAILURE

  • 0 0.3 0.4 0.3 0.4 0.3 l

CESIGN/thSTALL ATION ERROR

  • O 0.0 - - - -

OF ERATI AG ERROR

  • 0 0.2 0.1 0.2 0.1 0.3 i MAlhTEAANCE EREDR* 0 0.0 0.1 - - - +

Ex1EREAL' O 0.0 - - - -

CTHER* O 0.0 0.1 - - -

Suttotal 0 0.5 0.7 0.5 0.5 0.6 i TOTAL 2 3.2 4.1 4.0 4.4 4.8 i i

I 1993 1992 1991 1990 1989 NO. OF WEEKLY WEEKLY WEEKLY WE E Kl.Y WEEKLY SCRAMS AVERAGE AVERAGE AVERAGE AVERAGE AVE R A.GE ERAw TYrf (YTD)

TCTAL AUT WATIC SCRAMS 2 2.4 3.1 3.3 3.2 3.9 f TOTAL MANUAL SCRAMS 0 0.9 1.0 0.7 1.2 0.9 t

i TOTALS MAY DIFFER BECAUSE OF ROUNDING OFF

  • Detailed breakdown not in ciatabase for 1991 and earlier ,

- EXTEEhAL cease included in EQUIPMENT FAILURE

- MAINTEkANCE ERROR and DESIGh/ INSTALLATION ERROR causes ircluded in OPERAtlWG ERROR

- OTHER cause included in EQUIPMENT FAILURE 1991 at 1990  !

ETS 14 Page: 1 11/24/93

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$2IEE  ;

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1. PLANT SPECIFIC DATA BASED ON INITIAL REVIEW OF 50.72 REPORTS FOR THE WEEK OF INTEREST. PERIOD IS MIDNIGHT SUNDAY THROUGH MIDNIGHT SUNDAY.

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.

1

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 Manual and Automatic Scrams for 1993 --(YTD 11/21/93)-- 156 i

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