ML20096G007

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Generic Implications of Reactor Trip Events in Dec 1991, Final Rept
ML20096G007
Person / Time
Site: Crystal River Duke Energy icon.png
Issue date: 01/10/1992
From:
FLORIDA POWER CORP.
To:
Shared Package
ML20096G005 List:
References
NUDOCS 9205220114
Download: ML20096G007 (23)
v • d • e


Text

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A'ITACllMENT II 8

FINAL REPORT JANUARY 10, 1992

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O GENERIC IMPLICATIONS OF REACTOR TRIP EVENTS IN DECEMBER 1991 O

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TABLE OF CONTENTS iI CHARTER . . . . . . . . . . . . . . . . . . . . 1 I OPERATIONS . . . ............... 2 MAINTENANCE . . . . . . . . . . . . . . . . . . 4 I

TRAINING . . - . . ............... 7 t

ENGINEERING . . . . . . . . . . . . . . . . . . 11

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SUMMARY

OF RECOMMENDED ACTIONS . . . . . . . . 13 i

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' CHARTER qutGIlyI: To determine whether any generic factors contributed to three reactor trip events occurring in the last quai'or of 1991 or whether there are any additional recommended actions that should be accomplished prior to restart.

$1pff: The investigation concentrated on the following functional areas:

Haintenance Operations Training Engineering and their relation to the plant trips and equipment failures that occurred since initial criticality following the 8H outage.

O MEMBERS: G. L. Boldt - Team Leader P. H. Ezell - Maintenance P. V. Fleming Operations B. J. Hickle - Training F. X. Sullivan - Engineering O 1

OPERATIONS f

A. Observation Each of the three reactor trips occurred while engaged in activities associated with changing plant / system configurations in support of plant startup or shutdown.

Recommendations

  • 1. Provide plant startup training to the specific shift (s) which will conduct the next startup.
  • 2. Ensure all shifts are knowledgeable about all three events (0SB, Night Order, or Training Summary)
3. Provide refresher training for available operators in the area of startups and shutdowns (with and without failures). Focus on realistic events that have occurred
  • or have a reasonably high probability of occurring.
8. Observation Shift activities were not adequately controlled as indicated by complex evolutions being performed and inappropriate actions (G) simultaneous accomplished during transients.

Recommendations

  • l. Reinforce obtaining concurrence prior to taking specific / defined actions (working in systems that can trip the plant) as addressed in Al-500. (058, Night Order)
  • 2. Reinforce obtaining concurrence (permission) from SRO prior to taking specific actions (bypass an ESF actuation). (0SB, Night Order)
3. Correct any information resource deficiencies. Revise procedures and operating practices as necessary to assure predictable / consistent operation of systems and plant evolutions (CD system and main turbine operation during startup/ shutdown, develop guidance for decreasing RCS pressure symptoms equivalent to existing RCS leakage guidance).
  • Denotes actions which should be taken prior to startup from this outage.

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p 4. Determine if shift staffing is appropriate in terms of balancing experience, competence, confidence, and command / control s+.yles.

5. Conduct a review and issue a report / recommendation regarding a proposed " Shift Manager" who would replace the " Man On Call".

Duties assigned to this position might include, but not be limited to, Emergency Coordinator, Outage Shift Manager, Start Up Manager, and Shift Maintenance Manager, among others.

C. Observation The current operator progression removes the most experienced people from the main control board operating position.

Big _qmmendation

1. Abolish six (6) Nuclear Operator (NO) positions and create six (6) Chief Nuclear Operator (CNO) positions. Utilize rotational schemes between the new CN0 positions and the existing CNO positions which maintain a higher level of experienced personnel at the main control board.

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A. Observation Several maintenance items were contributing factors to plant trips. While the maintenance items, except for RCV-14, were not the cause of the trips, they either required a plant shutdown to correct or they did not function properly during plant manipulations.

Re.cpapendationi

  • l. Review other work performed during the Midcycle 8 Outage to identify potential maintenance items that could cause plant transients. This review should include a review of the AHF-2A/2B work, work performed by contractors, MOVATS work, and equipment critical to plant operations (i.e., pressure, temperature, and reactivity control). From this review, develop a list of actions to be accomplished prior to plant startup (see attached Actions Required Prior to Startup on page 7).
2. Revise SP-324 to ensure that on the final RB walkoown, the reactor vessel seal plate is verified to be in the raised position.

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B. Qbservation The work control process did not require a review of the post maintenance testing on AHF 2A/2B (WR 2B7111) after the work was completed. The original work scope was troubleshooting the diffcrential pressure switches, and the post-maintenance testing was designed to test the functioning of these sw' tches. When the flow discharge camper was repositioned, the post-maintenance testing should have been reviewed and revised to functionally verify proper flow. The issue of expanded work scope without proper post-maintenance testing review / revision has generit. implications.

Recomendations

1. Evaluate methods to ensure post-maintensnce testing is reviewed / revised when the work scope significantly expands.
2. Evaluate methods- to involve system engineers more closely with maintenance and post-maintenance testing on their systems.
  • Denotes actions which should be taken prior to startup from this outage.

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C. Observelan  ;

The documentation on some field work performed did not provide sufficient information to determine what was done, and in what sequence, or that the work was~ accomplished as instructed.

Recomendations l

1. Emphasize providing adequats documentation on work performed with l first line supervisors. Consider the quality of documentation as 4

- a' performance goal for first line supervisors.

2. = Evaluate methods for monitoring the quality of the work package  ;

completion information.

D. Observation Maintenance personnel worked excessive overtime-(sometimes in excess of 80 hours9.259259e-4 days <br />0.0222 hours <br />1.322751e-4 weeks <br />3.044e-5 months <br /> per two week period) during the 8M outage. This could be a  ;

contributing factor to the AHF 2A/2B damper scenario.

Recommendation

1. Evaluate why excessive overtime was. worked, and take the necessary actions to bring overtime to an acceptable level for future outages.

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/ ACTIONS RE0VIRED PRIOR TO START-UP ACTION 11AES

1. Verify RV seal plate installed Complete in raised position
2. Verify AHF 2A/B flow Complete
3. Repair Main Generator Hydrogen leaks Complete
4. NI-6 cable and detector replacement Complete
5. AHF-1A high bearing temperature repair Declared Inoperable
6. Eng. to verify RCP vibration alarms sat. Complete
7. Control Rod Drive indications repaired Ccmpiete
8. ASV-28,29,30 verifief to operate properly Complete HUV-40 operates properly from Complete p) 1, 9.

control room

10. Pressuri:er Heaters troubleshooting / Complete repair
11. Engineering to provide instructions Complete to Operations on start of AHF-2A and AHF-2B to hold pistol grip in start position 20 seconds after damper open indication received.
12. RCV-14 repair Complete i

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e TRAlHING A. Observation Plant startups involve complex operations which require increased attention to detail, procedural familiarity, and team coordination. Operating crews perform plant startups on the simulator only once a year as part of their operator requalification training. Actual plant startups have been performed by crews which have not had recent startup experience and, in some cases, have not practiced as a whole crew on the simulator because crew composition has changed since the date of last simulator training.

Reconsnendations

1. 0)erating crews performing plant startups after long outages s1ould first practice a startup on the simulator.
2. Startup crews should be supplemented with additional operators to perform tasks in support of the startup so that undivided supervisory attention can be given to startup operations from the time when reactor startup commences until plant is at = 60%

power.

(NOTE: Extra coverage snould be discretionary during startup physics testing power level holds.)

8. Observation During the most recent transient, operators pulled rods multiple times in an attempt to restore RCS pressure wlile depressurization went on for about twenty minutes until the reactor tripped. Increasing power to correct an RCS pressure decreasing transient is a non-conservative operating practice because heat and radioactive inventory are being added to the system at a time when plant response was not understood by the operating crew.

Recommendation

1. Operations and training staff should review operator actions during this transient, and determine whether or not remedial training is required for the shift that was on duty.

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C. Observation During the most recent event, the high pres ea insection system was bypassed on two separate occasions before it cL. d automatically actuate.

The first time the operator at the controls removed the bypass after thinking over his actionst the second bypass was preplanned by the crew.

The appropriateness of the operator actions have been the subject of debate by various review groups. According to the training staff, no specific guidelines are available to the training department to train operators on the general requirements / philosophy for bypassing safety systems prior to actuation (except for the procedural guidance which covers some limited specific situations).

Recommendations

  • 1. Develop a clear and consistent guideline for bypassing safety functicas.
  • 2. Train operators on guideline.

D. Qhigrvation Over the past few years, training emphasis has increased in the area of -

preparing operators to cope with severe transients, largely in response to NRC requirements. Also " lessons learned" training is continually factored into the training program '.s a result of operating experience reviews.

OV These changes to the training program have caused a decrease in the amount of time and emphasis placed on normal operations.

Recomendations

1. Review the scope of training provided to operators, and identify opportunities to emphasize training which would enhance normal operations.
2. Ensure th 6 " lessons learned" items added to operator training program receive review and approval of operations and training staff prior to revising training program.

E. Observation It has been identified that the shift crew on duty during the last trip has some weaknesses in the areas of tea. work and diagnostic skills. This has been observed during training sessions on the simulator. The two N0s on the shift were recently assigned to control board duties and have not trained with the balance of the shift on the simulator. The ANSS and SS00 are viewed as having similar leadership styles (i.e., to the degree that they may not fully offset cach other's strengths / weaknesses).

' Denotes actions which should be taken prior to startup from this outage.

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l Recomendations O 1. Review shift crew composition and restructure shift or provide special simulator training to strengthen team (applies only to shift involved with last trip). Do this prior to allowing shift to operate. Solicit training department input to address this issue.

2. Review current methods for determining shift crew composition.

Revise these where enhancements can be made.

F. Observation j Operating crews could benefit from a heightened " questioning attitude."

Some of the actions taken during the transients reviewed may have been different if plant systems and response had been questioned a little more and annunciator response procedures had been used as a diagnostic tool.

Recommendations

1. Review training programs and identify methods to develop the

" questioning attitude" of shif t. - Enhance training program as appropriate. This should be reinforced by line management during simulator sessions and control room observations.

2. Ensure training that is conducted on the simulator evaluates the shift willingness and capability to use outside resources in O decision making. (For example, exercises could involve man on-call or engineer on call consultations.)
3. Emphasize the use of annunciator response procedures and other diagnostic tools during simulator training.

G. Observation During the last plant transient, the operating crew and the OTA on duty had difficulty diagnosing the problem as a stuck open pressurizer spray valve.

According to - the training staff, some OTAs have exhibited occasional difficulty with basic concepts. 1he- training staff has had difficulty training to standard performance measurements for OTAs since they are used inconsistently on the operating shifts (as observed during simulator training).

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  • Denotes actions which should be taken prior to startup from this outage.

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,e Ettomendations

( l. Clearly define the role . of the OTA, and develop detailed performance standards to train to.

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2. Review the OTA training and qualification program and revise where necessary to improve OTA diagnostic skills. Include additional emphasis on application of thermodynamic principles to operational events.
3. Identi fy mechanisms to increase operational experience and familiarity, and provide for improved teamwork between OTA and balance of crew. Evaluate placing OTA on shift.
4. Ruview and revise, as necessary, verification procedures to ensure ease of use and to make sure their uso does not dilute ]

OTA's ability to get the " big picture".  ;

5. Consider developing aides for operators and OTAs to improve diagnostic capabilities (flow t,narts are ustd at some plants).

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ENGINEERING O

A. Observatign ,

Since 1980, there has been a significant amount of documented problems associated with the pressurizer spray valve RCV-14. Since Refuel 7, RCV-14 has failed three times. RCV-14 has two associated limitorque operators that have been changed out when problems with the mounted operator are identified. Both operators have displayed limit switch indication problems, and the operator that was mounted to RCV-14 during the startup from BM failed partially open during the December 8, 1991, transient. It should be noted that this particular operator has failed in a similar manner (reference NCOR 90 122).

Recommendations

  • l. Clearly identify the root cause for the most recent RCV-14 failure.
2. Evaluate the long term maintenance history of RCV-14, and initiate any additional long term corrective actions.
3. Review the existing mechanisms utilized to identify plant components with long term maintenance histories that may result in a forced shutdown. Evaluate methods to accelerate the O' identification process. Once identified, the priority components should be analyzed for corrective actions. The corrective actions should then be presented to plant management for scheduling and budgetary funding.

B. Observation During interviews with the system engineering organization concerning the RCV-14 failure and the AHF 2A/2B damper problem, it became apparent that both the organizations' management and engineers are frustrated by their ,

limited ability to perform the perceived vital system engineering functions. The identified vital functions include the performance of detailed system walkdowns, monitoring / enhancing system perforniance, component failure analysis, post-maintenance test development / review, and improved involvement of maintenance planning / activities. The reasons identified for limiting the performance of these vital functions include heavy burdens in procedure review / development, " Problem Report" analysis, and vendor technical information reviews. The system engineering organization has been in place for approximately two and one-half years.

The organization was founded to improve system / plant performance through the initiation of the aforementioned vital taAs.

  • Denotes actions which should be taken prior to startup from this outage.

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Recomendatigni

1. Initiate a time study of the system engineers' daily activities over an acceptable time frame (including outage time),

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2. Plant / engineering management should evaluate the time study data and determine corrective actions.
3. Ensure " vital" engineering functions are tracked by performance indicators which are visible to senior management.

C. Observation During the review of the NI 2 and RCV-14 trouble-shooting efforts, it became apparent there is a need for a consistent methodology for component trouble-shooting / root cause determination during periods of forced outages.

Improvements in data recording, concise problem analysis, true single point of accountability, corrective action plan documentation / control, and accurate turnover documentation may be warranted.

Recomendations

1. Establish a minimum set of criteria that should be utilized during component trouble-shooting / root cause determination (i.e.,

time-lir.e of known events prior to the failure, expectations of proper component performance, "as found" field data taken during 73 the course of trouble shooting, etc.)

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2. Establish good "brsinstorming" practices.
3. Develop consistent sinale point of accountability responsibili-ties.
4. Develop a consistent method for issuing / modifying trouble-shooting and corrective action plans.

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SUMMARY

OF RECOMMENDED ACTIM I (o'~) ACTION ASSIGNED TO, DE Okt' RATIONS *Al Training for shift which will restart D. Porter Complete the plant 1

  • A2 OSB entries for all three trips D. Porter Complete j A3 Refresher S/V training for available D. Porter Complete  ;

operators l

  • B1 Reinforce HOC concurrence for required D. Porter Lnplete actions (especiallyworkinsystemsthat can trip the plant)
  • B2 Reinforce SRO concurrence for required D. Porter Complete actions (especially bypassing ES)

B3 Correct any information resource D. Porter 3/1/92 deficiencies B4 Balance shift staffing D. Porter Complete B5 Review " shift manager" concept P. McKee 3/1/92 C1 Additional CN0's on shift D. Porter 3/1/92 MAINTENANIE *Al Review other SM work P. Ezell Complete A2 Revise SP-324 D. Porter 2/1/92 B1 Evaluate methods for review of PHT K. Lancaster 4/1/92

(]v when WR scope expands 82 Evaluate methods to involve system G. Halnon 4/1/92 engineers more closely in maintenance Cl Improve documentation of work performed H. Koon 4/1/92 C2 Monitor quality of work package K. Lancaster 4/1/92 completion D1 Reduce maintenance overtime in futuro H. Koon 3/1/92 outages TRAtRIE Al Provide S/U training prior to S/U L. Kelley 6/1/92 in future outager, A2 Supplement operating crews during S/U's W. Mar: ball 4/1/92 B1 Remedial training for shift on duty L. Kelley Complete during trip #3

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n *Cl Develop guideline for bypassing D. Porter Complete

( ') safety functions

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  • C2 Train operators on guideline D. Porter Complete D1 Enhance operator training in L. Kelley 6/1/92

" normal operations" D2 Review / approval of lessons learned L. Kelley 3/1/92

  • El Restructure composition of crew on D. Porter Complete duty during trip #3 E2 Review shift composition practices W. Marshall 3/1/92 F1 Develop questioning attituda W. Marshall 3/1/92 F2 Involve HOC /SOTA/ Engineer L. Kelley 3/1/92 on call in simulator exercises F3 Emphasize use of annunciator W. Marshall 3/1/92 response procedures G1 Define role of SOTA P. Alberdi 4/1/92 G2 Improve training on SOTA diagnostic W. Bandhauer 4/1/92 skills G3 Enhance operational experience and W. Bandhauer 4/1/92 teamwork opportunities for 50TA's Ensure verification procedures G4 W. Bandhauer 4/1/92 do not dilute OTA ability to "get the big picture" Develop diagnostic aides for OTA's W. Bandhauer 6/1/92 fl V

-G5 ENGINEERING *Al Define root cause for RCV-14 C. Halnon Complete A2- Evaluate RCV-14 history G. Halnon 4/1/92 A3 Accelerate failure history review G. Halnon 4/1/92 for other equipment

-81 Time study system engineering activities G. Halnon 9/1/92

.B2 Take corrective action G. Halnon 12/31/92 B3 Establish performance indicators for G. Halnon 4/1/92 vital functions ,

Ci Establish root cause criteri: G. Halnon 6/1/92 C2 Establish " brainstorming" practices G. Halnon 6/1/92 C3 Establish single point of accountability P. McKee 6/1/92 resporsibilities/ practices C4 Establish method to issue troubleshooting / G. Halnon 6/1/92 correction action plans Denotes actions which should be taken prior to startup from this outage.

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Attachment 111 GENERIC IMPLICATIONS OF REACTOR TRIP EVENTS IN DECEMBER 1991 Page 1 ITEM ITEM DESCRIPTION ITEN STATUS _

OPERATIONS Training for shift Al Complete which will restart the plant A2 OSB entries for all Complete three trips I

A3 Refresher S/U training Complete for available operators

B1 Rtinforce MOC Complete concurrence for required actions (especially work in systems that can trip the plant)

B2 Reinforce SR0 Complete concurrence for required actions (especially bypassing "ES")

B3 Correct any information Complete resource deficiencies l

l 84 Balance shift staffing Complete

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Attachment til GENERIC IMPLICATIONS OF REACTOR TRIP EVENTS IN DECEMBER 1991 Page 2 ITEM IfEM DESCRIPTION ITEM STATUS OPERATIONS B5 Review " Shift Manager" Complete concept Cl Additional CN0's on Complete shift ITEM ITEM DESCRIPTION ITEM STATUS MAINTENANCE Al Review other BM work Ccaplete A2 Revise SP 324 Complete B1- Evaluate methods for Open-review of PMT when WR scope expands The evaluation of methods for review 4 of PMT when WR scope has expanded has been completed. Instruction for re-evaluatinn and post maintenance test review will be provided more explicitly.in the next-revision to CP-ll38 unich will be cumpleted by August 31, 1992. This completion date is consistent with. existing goals to re evaluate the entire work control process. As an interim action, training ha., been provided to shep supervisors regarding the need to have work Jackages reviewed for PMT changes wien the WR scope is changed.

f, Attachment !!!

GENERIC IMPLICATIONS OF REACTOR TRIP EVENTS IN DECEMBER 1991 Page 3 ITEM ITEM DESCRIPTION ITEM STATUS

. MAINTENANCE _

B2 Evaluate methods to complete  !

involvo System l Engineers more closely in maintenance Cl Improve documentation Open of work performed A comprehensive plan has been identified to improve documentation of work performed. This plan includes the following: 1) Develop written standards for work package documentation; 2) 'evelop written standards for shop log keeping; 3)  ;

Train personnel on items 1 & 3; and

3) Implement a review of worL package documentation. These actions will be completed by 8/28/92, C2 Monitor quality of work Open package completion Guidance to accomplish this activity will be included in the next-revision to CP 113 which will be complete by.

August 31, 1992. This is consistent with existing goals to re-evaluate the entire work control process.

D1 Reduce maintenance Complete overtime in future outages--

ITEM ITEM DESCRIPTION ITEM STATUS TRAINING Al Provide S/U training Complete prior to S/U in future outages I "-

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GENERIC IMPLICATIONS OF REACTOR TR!P EVENTS IN DECEMBER 1991 Page 4 l

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_ ITEM ITEM DESCRIPTION ITfh STATUS _

TRAINING i A2 Supplement operattsg Complete l crews during S/U's B1 Remedial training for Complete shift on duty during trip #3 Cl Develop guideline for Complete bypassing safety functions C2 Train operators on Complete guideline 01 Enhance operator Complete training in " normal operations" D2 Review / approval of Complete

'iessons learned El Restructure composition Complete of crew on duty during trip 13

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Attachment'III l GENERIC IMPLICATIONS Oc PCACTOR TRIP EVENTS IN DECEMBa1991 page s-1 ITEM IT8M DESCRIPTI0ll- __

ITEM STATUS

-TRAINING _

E2 ' Review shift Complete composition practices F1 Develop questioni,'g Complete attitude

- F2 - Involve .

Complete H0C/S01A/ Engineer on call . in simulator-excercises l

F3 Emphasize use'of Complete annunciator respese procedures GI-- Define role of the SOYA- Complete G2 Improve training on- Open S0TA diagnostic sk_ ills The current schedule for-completion of this item is 7/15/92 G3 Enhance operational .

Complete experience and teamwork-opportunities'for. ,

.b- SOTA's-

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GENERIC IMPLICATIONS OF REACTOR TRIP EVENTS IN. DECEMBER-1991 Page 6 ITEM ITEM DESCRIPTION ITEM-STATUS TRAINING G4 Ensure verification Open 8 procedures do not dilute OTA ability to Accomplishment of this item involves "get the big picture" revisione 'o VP-540 and VP-580.- The revision , VP-540 is complete. The revision is !P-580 is in progress and-is expec;c to be complete by 8/31/92 G5 Develop diagnostic aids Open for OTA's The curront completior, date for this item is 1/31/93 s . . _ -

ITEM ITEM DESCRIPTION ,

ITEM STATUS ENGINEERING Al Define Root Cause'for Complete RCV-14 A2 Evaluate RCV-14 history Complete l

RCV-14 history is contained in failure analysis 91-RCV-14-01 L

t A3 Accelerate-failure Complete E- history review for

. otht? equipment

-5 L BL Time study-System Open L Engineering activities This remains on schedule to be

' complete by 9/1/92 l'

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, Attachment 111 GENERIC IMPLICATIONS OF REACTOR TRIP EVENTS IN DECEMBER 1991 page 7 ITEM ITEM DESCRIPTION ITEM STATUS ENGINEERING BP_ Take Corrective action Open This remains on schedule to be complete by. 12/31/92 1 Establish. performance complete

-indicators for vital.

functions

< Establish Root Cause Open criteria This remains on schedule to be complete by 6/1/92 C2 Establish Complete

" brainstorming" practices C3 Establish single point Complete of accountability l

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C4. Establish method to Open

, issue troubleshooting / -

l correction action plans This remains on schedule to be complete by 6/1/92 l

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