ML20059J807

Summary of Operating Reactors Events Meeting 94-02 on 940112

ML20059J807
Person / Time
Site:	Quad Cities, LaSalle
Issue date:	01/19/1994
From:	Chaffee A Office of Nuclear Reactor Regulation
To:	Grimes B Office of Nuclear Reactor Regulation
References
OREM-94-002, OREM-94-2, NUDOCS 9402010191
Download: ML20059J807 (17)

Text

,

JMr I s 24 MEMORANDUM FOR:

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

Alfred E. Chaffee, Chief Events Assessment Branch j

Division of Operating Reactor Support i

SUBJECT:

OPERATING REACTORS EVENTS BRIEFING JANUARY 12, 1994 - BRIEFING 94-02 On January 12, 1994, we conducted an Operating Reactors Events Briefing (94-02) to inform senior managers from offices of the i

Commission, OE, OEDO, RES, NRR, AEOD, and regional offices of selected events that occurred since our last briefing on January 5, 1994. lists the attendees.

f presents the significant elements of the discussed events. contains reactor scram statistics for the week ending January 9, 1994.

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

r Nod hoodA0 j

Alfred E.

Chaffee, Chief Events Assessment Branch Division of Operating Reactor Support

Enclosures:

As stated cc w/ enclosures:

See next page DISTRII}yTION:

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T. Murley, NRR (12G18)

C. Patel (PDIII-2) h.

F. Miraglia, NRR (12G18)

J. Dyer (PDIII-2)

F. Gillespie, NRR (12G18)

A. Gody (PDIII-2)

J. Callan, NRR (12G18)

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)

M. Hodges, 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 (2GS)

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. Greenman, Region III J.

Milhoan, Region IV B.

Beach, Region IV B.

Paulkenberry, 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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UNITED STATES

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WASHINGTON, D.C. 20E0001 K 191994 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 JANUARY 12, 1994 - BRIEFING 94-02 On January 12, 1994, we conducted an Operating Reactors Events Briefing (94-02) to inform senior managers from offices of the Commission, OE, OEDO, RES, NRR, AEOD, and regional offices of selected events that occurred since our last briefing on January 5, 1994. lists the attendees.

presents the significant elements of the discussed events. contains reactor scram statistics for the week ending January 9, 1994.

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

)

Alfred E.

Chaffee, Chief Events Assessment Branch Division of Operating Reactor Support

Enclosures:

As stated cc w/ enclosures:

See next page e

ENCLOSURE 1 LIST OF ATTENDEES OPERATING REACTORS EVENTS FULL BRIEFING (94-02)

JANUARY 12, 1994 HAME OFFICE NAME QFFICE T. GREENE NRR J. WERMIEL NRR R.

DENNIG NRR C. ROSSI NRR E.

GOODWIN NRR M. VIRGILIO NRR K. GRAY NRR B. GRIMES NRR J.

DYER NRR J.

BEALL OE T. YAMADA NRR R. ROBINSON RES S. ROSENBERG NRR W. DEAN OEDO K. DESAI NRR V. BENAROYA AEOD C.

PATEL NRR J.

SORENSEN OCM/KR J. ROE NRR M.

FLEISHMAN OCM/KR TELEPHONE ATTENDANCE (AT ROLL CALL)

Reaions Resident Insoectors Region I Region II Region III Region IV Region V

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IIT/AIT Team Leaders Misc.

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' ENCLOSURE.2-3 f

OPERATING REACTORS EVENTS BRIEFING 94-02 LOCATION:

10 Bil, WHITE FLINT

- WEDNESDAY, JANUARY. 12, 1994 11:00 A.M.

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--0UAD CITIES, UNIT 1 REDUCED SHUTDOWN COOLING FLOW-

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LASALLE, UNIT 2 CONTAMINATION OF WORKERS 9

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' PRESENTED BY:

EVENTS ASSESSMENT BRANCH DIVISION OF OPERATING' REACTOR SUPPORT, NRR

94-02 QUAD CITIES, UNIT 1-j REDUCED SHUTDOWN-COOLING FLOW NOVEMBER 11,, 1993 l

PROBLEM FORCED CIRCULATION.THROUGH THE CORE WAS. TERMINATED.

SOME OF THE SHUTDOWN-COOLING WATER FLOW WAS PERMITTED TO BYPASS THE CORE AND THE REACTOR COOLANT TEMPERATURE INCREASED.

CAUSE THE IB RECIRCULATION PUMP DISCHARGE VALVE WAS DELIBERATELY OPENED; THE 1A RECIRCULATION PUMP DISCHARGE VALVE WAS ALREADY OPEN AND SHUTDOWN COOLING FLOW WAS INTO THE "B" l

LOOP.

f, SAFETY SIGNIFICANCE WITH.AN UNDETERMINED AMOUNT OF CORE BYPASS FLOW, IT IS POSSIBLE THAT REACTOR COOLANT TEMPERATURES COULD INCREASE-AB0VE DESIRED LEVELS.

3 i

RISCMSSION j

e UNIT 1 WAS IN COLD SHUTDOWN FOR A MAINTENANCE OUTAGE WHICH BEGAN 11/5/93 e

RECIRCULATION PUMP "B" WAS OPERATING WITH BOTH THE "B" AND "A" DISCHARGE VALVES OPEN.

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CONTACT:

R. DENNIG, EAB/ DORS AIT: HQ_

REFERENCE:

10 CFR 50.72 #26360 SIGEVENT: IRQ i

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QUAD CITIES', UNITL1 94-02 e.

IN_ PREPARATIONLFOR VOTES TESTING OF.LPCI VALVES, l

REACTOR WATER LEVEL WAS INCREASED TO 90 INCHES FOR NATURAL CIRCULATION, AND THE "B" RECIRCULATION PUMP'WAS.

l TRIPPED (DISCHARGE VALVE CLOSED).

~ e' OPERATORS WERE CONCERNED ABOUT THE "B" LOOP DELTA-T LIMIT AND THE POSITION OF THE "B" LOOP DISCHARGE VALVE-j CORE BYPASS OR DEGRADATION OF SHUTDOWN COOLING WAS.

4 NOT CONSIDERED.

j THE OPERATORS DECIDED TO OPEN THE VALVE.

DESIRED-REACTOR COOLANT TEMPERATURE FOR TESTING WAS AT THE UPPER END OF THE TEMPERATURE RANGE OF 140F TO 180F.

e OPERATORS WERE MONITORING METAL TEMPERATURES AND HEAT EXCHANGER INLET TEMPERATURES.

TEMPERATURES WERE DELIBERATELY INCREASED, FROM 127F 1

TO 165F.

SHUTDOWN COOLING FLOW WAS ADJUSTED TWO TIMES T0-INCREASE FLOW AS~ TEMPERATURE ROSE TO 180F.

ADJUSTMENT NOT EFFECTIVE DUE TO PARTIAL FLOW BYPASS 0F CORE.

L

QUAD CITIES, UNIT 1 94-02 SUBSEQUENT TO A SHIFT CHANGE, IT WAS NOTICED THAT, PER A STEP IN THE PROCEDURE, THE "B" DISCHARGE VALVE SHOULD BE CLOSED.

VALVE WAS THEN CLOSED.

COOLANT TEMPERATURE, WHICH HAD INCREASED TO 189F, THEN DECREASED.

e TECHNICAL SPECIFICATIONS LIMIT MAXIMUM TEMPERATURE DURING COLD SHUTDOWN CONDITION TO 212F.

FOLLOWUP e

LICENSEE REPORTED THE OCCURRENCE AS ONE THAT COULD HAVE PREVENTED THE FULFILLMENT OF A SAFETY FUNCTION, REMOVING RESIDUAL HEAT.

e A SPECIAL INSPECTION WAS CONDUCTED (50-245/93031).

TRAINING, PROCEDURES AND DRAWINGS WERE NOT ADEQUATE.

e ALSO IDENTIFIED BY RECENT DIAGNOSTIC EVALUATION (DET) e A SEVERITY LEVEL IV VIOLATION WAS ISSUED; FAILURE TO FOLLOW PROCEDURES.

e LICENSEE SUBMITTED DET CORRECTIVE ACTIONS IN LETTER DATED 12/30/93.

BRIEFING 94-02 QUAD CITIES h

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LASALLE, UNIT 2 l

CONTAMINATION OF WORKERS SEPTEMBER 7, 1993 l

P10B1EM TWENTY-TWO. WORKERS WERE. CONTAMINATED, 17 OF WHOM RECEIVED

. MEASURABLE INTAKES OF RADI0 ACTIVE MATERIALS.

CAUSE.

h THE CAUSES OF THE EVENT INCLUDED INADEQUATE PLANNING, LACK 0F MANAGEMENT AND FIRST LINE SUPERVISORY OVERSIGHT OF THE.

RADIATION PROTECTION TECHNICIANS (RPT), INEFFECTIVE j

. TRAINING OF THE'RPT AND RADIATION WORKERS, THE. LACK OF A j

QUESTIONING' ATTITUDE OF RPT AND WORKERS CONCERNING THE 1

WORK: ENVIRONMENT, POOR COMMUNICATIONS, A LACK OF.-

i UNDERSTANDING OF HOW THE VENTILATION SYSTEM'0PERATION.

j AFFECTS RADIOLOGICAL CONDITIONS', AND AN INADEQUATE REVIEW 0F INFORMATION NOTICE 92-75, " UNPLANNED INTAKES OF AIRBORNE RADI0 ACTIVE MATERIAL BY. INDIVIDUALS AT. NUCLEAR i

POWER PLANTS."-

SAFETY SIGNIFICANCE ALTHOUGH THE-RADIATION DOSES RECEIVED BY THE WORKERS WERE 3

WITHIN REGULATORY LIMITS, THE PROGRAMMATIC WEAKNESS IN THE LICENSEE RADIATION PROTECTION PROGRAM REVEALED BY THIS EVENT ELEVATED IT TO A SIGNIFICANT EVENT.

CONTACT:

T. GREENE, NRR/0EAB AIT: _10

REFERENCE:

ENFORCEMENT ACTION 93-235 SIGEVENT: IBR 1

i LASALLE, UNIT 2 94-02 DISCUSSION ON SEPTEMBER 7, 1993 A PRE-J0B MEETING WAS HELD TO o

DISCUSS THE PARTICULARS OF DISASSEMBLING THE REACTOR VESSEL HEAD.

ALTHOUGH THREE RPTs ATTENDED THE MEETING, THE DISCUSSION OF RADIOLOGICAL CONTROLS WAS LIMITED.

INITIALLY, THE TWO RPTs ASSIGNED TO THE JOB WATCHED THE o

WORK FROM THE REFUELING FLOOR.

THEY DID NOT ENTER THE REACTOR CAVITY NOR DID THEY TAKE AIR SAMPLES OF THE CAVITY.

e EVEN THOUGH THE CONTAMINANT LEVEL IN THE WORK AREA WAS ELEVATED EN0 UGH TO REQUIRE THE WORKERS TO WEAR RESPIRATORS, THE WORKERS WERE NOT WEARING THEM AS REQUIRED BY PROCEDURE.

THERE WERE NO ENGINEERING CONTROLS, SUCH AS HIGH EFFICIENCY PARTICULATE AIR FILTER VENTILATION OR PNEUHATIC TOOL AIR EXHAUST DIFFUSER TO LIMIT CONCENTRATIONS OF RADI0 ACTIVE MATERIALS IN THE AIR.

WHEN A THIRD RPT RELIEVED ONE OF THE RPTs ON THE REFUELING FLOOR, THE THIRD RPT NOTICED THAT ONE OF THE TWO CONTINU0US AIR MONITORS ON THE FLOOR WAS ALARMING.

ABOUT THE SAME TIME, THE RPT WHO WAS RELIEVED NOTIFIED THE REFUELING FLOOR THAT HIS FACE WAS CONTAMINATED.

o THE WORKERS EXITED THE REFUELING FLOOR AND OPERATIONS WAS REQUESTED TO RESTART THE VENTILATION SYSTEM THAT HAD BEEN SECURED 15 MINUTES EARLIER.

e CONTAMINATION WAS DETECTED IN VARIOUS LEVELS OF THE REACTOR BUILDING DUE TO AIR FLOW THROUGH GAPS IN THE REFUELING FLOOR EQUIPMENT HATCH.

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94-02 LASALLE, UNIT 2 IN TOTAL, 22 WORKERS WERE CONTAMINATED,17 0F WHOH RECEIVED MEASURABLE INTAKES OF RADI0 A o

EDLLOKUfNRC CONDUCTED A SPECIAL INSPECTION FROM S o

THREE VIOLATIONS WERE IDENTIFIED:

1993.

E FAILURE TO ADEQUATELY EVALUATE THE JOB NECESSARY SURVEYS OF THE REACTOR CAVI (1)

JOB WAS IN PROGRESS; FAILURE TO USE ENGINEERING CONTROLS TO L (2) AIRBORNE RADI0 ACTIVITY IN THE REACTOR CAVITY; AN FAILURE OF THE WORKERS TO WEAR RESPIRA (3) ACCORDANCE WITH RADIATION PROTECTION P FOR FIRST EIGHT MONTHS OF 1993, STATION RADIATION PROTECTION MANAGER DID NOT ENTER ANY R o

CONTROLLED AREA.

THE OFFICE OF ENFORCEMENT ISSUED A CIV o

AMOUNT OF $112,500.

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ENCwSURE 3 aEactDa SCRAM

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Reporting Period: 01/03/94 to 01/09/94 TTO YTD ABOVE BELOW YTD M

PLANT & Uerff POWER E

Eqsg COMPLICATIDWs M

M E

01/07/94 VOCTLE 2 100 SA Equipnent Felture NO 1

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01/09/94

$AINT LUCIE 1 100 SM Equipment Failure NO 1

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dote:

Year To Date (YTD) Totals IrelLde Events Within The Calendar teor Indicated By The End Date of The Specified Reporting Period E15 10 page:1 01/12/94

{.

COMPARi$oN of WEEKLY SCRAM STATISTICS WlfM INDUSTRY AVERAGES PERico ENDING 01/09/94 1993 1992 199l' 1990*

1989*

spesER 9g WEEKLY WEEKLY WEKLY WEKLY WEEKLY of gy AVE R ACE AVERAGE AVERAGE AVERAGE AVERAGE gR Ap ( AUS1 SCRAMS AW M (VfD) power GREATER THAN oR EcuAL to 15%

foulPMENT FAILURE

• 2 1.6 1.8 2.6 2.9 3.4 3.1 oEsiGw/!nsTALLAtion ERRon*

o 0.0 00 OPERATING ERROR

• o 0.0 0.3 c.2 0.6 0.5 1.0 MAiutE u= E ERRon*

o 0.0 05 0'

EXTERNAL

• o 0.0 01 c1 ER*

o 0.0 0.0 0.2 o.1 Slitotal 2

1.6 2.7 3.A 3.5 3.9 4.2 POWER LES$ THAN 15%

Ecu!PMEnt FAILURE

• o 0.0 0'

0' 03 0.'

O.3 Des!cunwstAttAtion Esmon*

o 0.0 0.0 oryAtisG ERw o

0.0

.1 0.1 c.2 o.3

.. tf u=:E ERROR

• o 0.0 00 01 ExttFhAL*

o 0.0 00 00 01 01 hen

• o 0.0 5

07 05 05 06 subtetal o

0.0 101AL 2

1,6 3.2 4.1 4.o 4.4 4.8 1993 1992 1991 1990 1,9 jgrg WE EKLT WEKLY WEEKLY WEEKLY WEEKLY Wo. OF Q[Q'y sesaw TvFE sta&Ms AWM^f AVERACE AVERAGE AVERAGE AVERAGE AVE RACE (VfD) 2.'

3.1 3.3 3.2 3.9 total AJ1oMATIC SCRA*S 1

0.8 101 AL MAWuAL 5tR A*5 1

0.8 c.9 1.0 0.7 1.2 c.9 TOTALS MAY DIFFER BECAU$E of ROUND!kG off

• Detailed breakdown not in database for 1991 and earlier

• ExTER6AL cause included in Ecu!PMEh1 FAILURE MAIN 1ENAhCE ERROR and DEllCN/lW5fALLAT Od EEROR causes included in OPERATING ERROR C1HER cause inc1uded in EoulPMEN1 f A1 LURE 1991 and 1990 Eisd4 P80et i c1/11/94

i NOTES 4

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 WI'13 A PLANT PROCEDURE.

THERE ARE 111 REACTORS HOLDING AN OPERATING LICENSE.

2.

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

3.

COMPLICATIONS: RECOVERY COMPLICATED BY EQUIPMENT FAILURES.A 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 ------------------ 212 176 Manual and Automatic Scrams for 1993 002 Manual and Automatic Scrans for 1994 l

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