ML20100E191
| ML20100E191 | |
| Person / Time | |
|---|---|
| Site: | Quad Cities  |
| Issue date: | 11/07/1984 |
| From: | Rybak B COMMONWEALTH EDISON CO. |
| To: | James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| References | |
| 9418N, NUDOCS 8412060164 | |
| Download: ML20100E191 (1) | |
Text
c hm0 f'~'Ni Commonwealth Edison
(
) One First NTtion!! Plus, Chic 1go, litinois
'( g Chicago, Illinois 60690 T
] Addr:ss Rply to: Post Offica Box 767 N
November 7, 1984 f
Mr. James G. Keppler Regional Administrator U.S. Nuclear Regulatory Commission Region III 799 Roosevelt Road Glen Ellyn, IL 60137
Subject:
Quad Cities Station Unit 2 Presentation Material -
Enforcement Conference on October 25, 1984 Event NRC Docket No. 50-265-
Dear _Mr. Keppler:
Enclosed is a copy of the material presented by Commonwealth Edison during the Enforcement. Conference held to discuss the subject matter on November 5, 1984.
Should you'have any additional questions regarding this matter, please contact this office.
Very truly yours, 6f C
B. Ry a Nuclear Licensing Administrator
-lm
' Enclosure B412060164 e41107 PDRADOCK05000g S
. 9418N g (
CONFIRMATORY ACTION LETTER UNITED STATES s nasu.
NUCLEAR - REGULATORY COMMisslON
~
f REGION iH
.ri 799 ROOSEVELT RC AO 5
t GLEN ELLYN. ILLINOIS 60137 0CT29'M d
'0CT 2
- v4 stouTD A tAsst. soot.) _
g iOperatioosi __
~ ~ #a ateas'c
c Docket No. 50-254 Docket No. 50-265
,,,,n. 6 T.cn.
~ i cor.onne*
Connonwealth Edison Company
~
ATTN: Mr. Cordell Reed Vice President c
Post Office Box 767 west Chicago, IL 60690 Gentlemen:
This letter confims the telephone conversation on October 25, 1984, between Mr. C. Norelius and others of this office and Mr. N. Kalivianakis of your staff regarding the events surrounding the trip and failure of a control rod to scram at Quad Cities, Unit 2, on October 25, 1984. With regard to the.
h following:
matters discussed, we understand that you have or intend to do t e Conduct tests on the affected Control Rod Drive (CRD)-
1.
(38-51) for operability, e.g., Friction, Timing, Scram, and Stall Flow Tests prior to CRD removal.
2.
Remove and replace control rod drive (38-51) and conduct tests as appropriate..
Examine the internals of the removed CRD (38-51) for excessive wear 3.
or damage to seals and bushings on the stop and drive pistons, the index tubes, and the spring washers on the stop piston.
-Walkdown and verify the position of all manual valves in the CRD 4.
systems of Units 1 and 2.
Investigate to determine the root cause of the manual valve 112 being 5.
shut on CRD hydraulic control unit 38-51 and take appropriate corrective action.
Identify any instances where operations personnel may not have 6.-
perfomed within the scope of their responsibilities during *.nt; event and provide assurance that appropriate corrective actions
,~
will be taken.
Regarding Items 1, 2, 4, 5, and 6, we understand these items will be completed by you with RIII concurrence prior to unit restart.
Also, we understand you will provide a written sumary related to all of the items with your licensee event report (s).
CONFIRMATORY ACTION LETTER o,.
,i4 m ti n y o v a
3 2
Comonwealth Edison Company OCT 26 1984 Please let Us know imediately if your understanding differs from that set forth above.
Sincerely, AS
~
C mes G. Keppler Regional Administrator cc:
D. L. Farrar Director of Nuclear Licensing N. Kalivianakis, Plant
./c' Superintendent
's DMB/ Document Control Desk (RIDS)
Resident Inspector, RIII Phyllis Dunton, Attorney General's Office, Environmental Control Division W. Schultz, RIII R. Bevin, NRR C. Rossi, IE 4
O e
(
CONFIRMATORY ACTION LETTER
SHORT TERM CORRECTIVE ACTIONS a
PRIOR TO UNIT 2 STARTUP, ALL REQUIREMENTS OF THE COMPLETED EXCEPT NUMSER 3,
. CONFIRMATORY ACTION LETTER WERE THE EXAMINATI!ON OF.THE CONTRGL ROD DRIVE THAT WAS RE IN ADDITION THE FOLLOWING SHORT TERM COMMITMENTS WERE ITEMS 5 AND 6.
COMPLETED IN'RESPCNSE TO CAL'
.e 1
REVIEW WITH EQUIPMENT ATTENDENTS Ar4D EOUIPMENT 1.
CAL-5.
OPERATORS THE CLOSED CONDITION OF TriE SCFAM-ITS DISLt4 APSE RISER VALVE ON ROD K-13 AND
.~
EFFECT ON THE SCRAM FUNCTION.
DAILY INSTRUCT SHIFT FOREMEN TO PERFORM A 2.
CAL-5 SURVEILLANCE OF THE HYDRAULIC CONTROL UNIT VALVE POSITIONS.
REVIEW WITH THE OPERATORS THE IMPORTANCE OF 3.
CAL-6 REMAINING "AT THE CONTROLS" DURING UNIT OPERATIONS REVIEW WITH OPERATING FERSONNEL THAT SHIFT 4.
CAL-6 TURNOVER MUST NOT OCCUR DURING PLANT TPANSIEN IT IS REVIEW WITH OPERATING PERSONNEL THAT 5.
CAL-6 POSSIBLE FOR CONTROL' RODS TO EXPERIENCE UNSUCCESSFUL SCRAMS.
9 3
m
r
-t INVESTIGATION When I arrived at work on Thursday morning, October 25.
1984. I was met by the NRC Resident Inspector, Al Macison.
He' informed me of a secuence of events tnat occured on Unit 2 earl-ier in the morning.
1.
The reactor scr ammed f rcm h i gn ore s sure.
9
'2.
One of the control rods remainee at cesition aE iclicwing tne scram.
^
3.
The position of the roc anc its failure to scram was not discovered for 30 minutes after tne s c r am.
4.
He had l earned f rom an NSO arr i v i ng i n the control room at 6:45am tnat at that time it appe arec uni t
~
1 was unattended.
The next person that contacted me was the Assistant Superintendent for Operations.
He had been in the control room. si nce 7:30am and gave me-essen t i all y the-same information that I already had from the Resident Inspector.
He also informed me that the red phone call nad been made, a deviation report had been initiated and a potentially significant event investigation was in progress per the Nuclear Station Directives NSDD-A07, Potentially Significant Events and NSDD-A08, Plant Startup after Trip.
During the 8:15am morning call to the Corporate Office, our bosses were informed of the facts as we had them and we worked together ever since.
The operating supervisors and I continued the investigation 2
into the event.
The personnel involved from the nignt shift were unavail able so we decided to mee t wi th those i ndi v i dual s t h'+ f ol l owi ng morn i ng i n order to complete the sequence of events.
During the investigation we verified that the rod failed to scram.and 28 minutes elapsed before it was oiscovered.
We were able to determine very early in tne i.vestigation tnat the scram di scharge riser valve (EP. 305-112) was closec preventing the drive from venting properly at the elevatec pressure of the original scram. (When the second at temp t was made to scram the rod, the reactor pressure had decreased to
.less than 800 psig allowing the drive to vent through its-
. seals into the reactor vessel.)
We immediately attempted to determine the cause of the 112 valve being closed by reviewing the fo1104ing documents:
1.
Work requests subsequent to the refuel outage.
2.
Out of service requests subsequent to the refuel outage.
3.
The September 18th hot scram surve ill ance tests.
c 4.
Accumulater alcema 1cggod in tho uni t coorator'c Icg back cubcoquant to tho Soptcmoor hot ceram l
survoillanco toots.
5.
Similar work perfcrmed on mocules'in tne vicinity of K-13 or on the other unit.
I During the investigation, the question of tne unattencec unit was also adoresseo.
The original information that we were able to obtain_ indicated to us that during tne time perioc in question, 6:45am to 7:00am, the oay snift unit operator was present at the controls of Unit 1 frcm the time he arrived in the-control room (o:45am.) anc receiveo nis shift turnover.
However,_the interviews tnat we had the following morning with the operators that were present in the control room when the event was occuring indicated to us that there was another period of time that the Unst 1 operator was not present at the controls of Unit 1 Decause he was helping on the Unit 2 transient.
This occured between 6:30am. and 6:45am.
However, during this time tne Unit 1 operator returned to his unit on three different occasions.
During cur discussions with the night shift we became aware of some additional concerns that we f el t compelled to address:
1.
Controlling pressure in a subcritical reactor by inserting additional control rods.
2.
The capability of the SCRE to perf orm as a l eaoer in the control room during a' system transient.
-Such as:
a.
The SCRE performing a snift turnover during a period when a unit was not in a p
stable condition.
b.
The failure of the SCRE to recognize that there was a control rod that had not scrammed.
c.
The failure of the SCRE to recognize that the stable unit was not attenced for a period of time.
We have already held a meeting wi th the Shift Engineers anc the SCREs to discuss openly and plainly the concerns that we have as a resul t of this event.
We view this event as an least en example of operating that was disappointing and at one instance not acceptable.
The individuals that were involved in this meeting contributed freely in this discussion and provided valuable insight on their? views of this event.
Such as:
c-The SCREo ao o grcup oxproccod anxiety duo to 1.
thoir 1cck of oxperienco during trancionto and cbncrmal ovolutieno in the centrol room to perform as a -leader eventhough they feel very comfortaoie during normal operations and as an STA curing abnormal plant conditions.
2.-
The vagueness of the procedure that defines the operator's responsi bi l i t i e's f or being at the controls of his unit.
3.
The communications between the 5CREs in the control room and the Shift Engineer's office were hampered because the Shift Engineer's teleohone 4
was busy.
4, The lack of detail in the procedure for placing
'the reactor in hot standby.
5.
The RWM difficulties created by both the procedure and the equipment that distracted the operators and wasted valuable time.
6.
The difficulties with the RCIC when the operators attempted to use it to control reactor pressure.
(During this event the RCIC experienced an overspeed trip that had to be reset l oc al l y. )
by side with last week we have been working side During all and ARD (a human representatives from the corporate office factors consultant) in evaluating the event and determining the proper corrective actions.
We also worked very closely with the Resident Inspector keeping him informed of the f ac ts as they developed.
O t
e ew_..--,--.,.,-.-4-,.. -, -,,. - -,. - -
.-,-y-.,-,
UNIT 2 SEQUENCE'OF EVENTS October 24, 1984 1900 SHIFT FOREMAN FOUND EHC OIL LEAK ON NO. 4 STOP VALVE
- 2130, STARTED REDUCING LOAD TO ENTER HOT STANDBY Octccer 25,~19E4 0235 TRANSFERED AUX POWER 0326 GENERATOR OFF LINE 0445 REACTOR MODE SWITCH TO STARTUP/ HOT STAND 8Y 0546 0UTBOARD MSIVs CLOSED (IN HOT STANDBY).
0550 EHC PLNP OFF 0600 DUE TO REACTOR PRESSURE INCREASING, NIGHT SHIFT SHIFT ENGINEER INSTRUCTED NIGHT SHIFT UNIT 1 OPERATOR TO INSERT ADDITIONAL CONTROL RODS.
SHIFT ENGINEER LEFT CONTROL ROOM TO PERFORM SHIFT TURNOVER.
0625 NIGHT SHIFT SCRE COMPLETED SHIFT TURNOVER.
DAY SHIFT SCRE TOOK CONTROL OF CONTROL ROOM.
0630 EXPERIENCING PROBLEMS WITH RWM.
SCRE INITIATED RWM BYPASS PROCEDURE.
NIGHT SHIFT SHIFT ENGINEER COMPLETED SHIFT TURNOVER 0635 DAY SHIFT SCRE NOTIFIED shirt FOREMAN BY TELEPHONE (SHIFT ENGINEER'S.
4 TELEPHONE WAS BUSY) THAT PRESSURE WAS INCREASING AND THEY WOULD START RCIC TO CONTROL PRESSURE CENTER DESK NIGHT SHIFT OPERATOR ATTEMPTED TO START RCIC BUT IT TRIPP ON OVERSPEED.
0641 REACTOR SCRAM FROM HIGH PRESSURE (1044 PSIG). NIGnT 5HIFT UNIT 1 OPERATOR MANUALLY STARTED HPCI.
NIGHT SHIFT UNIT 1 OPERATOR COMPLETED SHIFT TURNOVER, RETURNED TO HELP Ct1 0645
- t. NIT 2.
NIGHT SHIFT SCRE DETERMINED THAT THERE WAS SATISFACTORY COVERAG
- _0650, 2 SO HE LEFT SITE.
REACTOR WATER LEVEL UNDER CONTROL WITH FEEDWATER SYSTEM 0654 DAY SHIFT UNIT 2 OPERATOR REQUESTED FULL CORE SCAN (DD-7)
DAY SHIFT UNIT 2 OPERATOR ATTEMPTED TO INSERT RODS ATrPOSITICN '0 RWM STILL INJECTING AN INSERT ERROR.
0700 DAY SHIFT SCRE NOTIFIED RESIDENT INSPECTOR, AL MADISON ROD 0709 NUCLEAR ENGINEER REQUESTED FULL CORE SCAN AND IDENTIFIED A (K-13) AT POSITION '48'.
i
+
t-fa 0710 REACTOR PRESSURE WDER CONTROL USING HPCI 0712 ROD K-13 SC cED SUCCESSFULLY FROM THE PROTECTION SYSTEM PANEL. -
i DAY SHIFT i.#1IT 2 OPERATOR REQUESTED FULL CORE SCAN TO CCNFIRF +__ :.C 0713
'l POSITION '00',
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REMAINED IN s HOT SHU~DCW4 CONDITION USINC-RCIC AND HPCI FOR FREEi'jdE
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PRESENTATION OUTLINE' I.
INTR 0-DIV. V.P. & GM 11.
OVERVIEW-STATION SUPT. OC III.
SEQUENCE OF EVENTS ASST. SUPT OPER. OC IV.
INVESTIGATION STATION SUPT. OC V.
AREAS OF CONCERN / CORR. ACT.
DIV. V.P. & GM 1) 112 VALVE MISPOSITIONED 2)
ONE R0D FULL OUT FOLLOWING SCRAM 3)
TURNOVER ACTIVITIES OPERATOR LEAVING RX CONSOLE 4) 5)
SCRE PERFORMANCE 6)
SUSCEPTABILITY AT OTHER CECO SITES VI.
CONFIRMATORY ACTION LETTER ASST. SUPT OPER. OC ITEMS / CORRECTIVE ACTION 1
.s
-,,..,.n.n n
,_-,---,_,,,nn, n -,-
n.n-=.,--.----..---.,--.--,
r-AREAS OF CONCERN - OVERVIEW SIX AREAS OF CONCERN IDENTIFIED TO D. FARRAR
, 1)
.112 VALVE ON CRD HCU MISPOSITIONED (CLOSED) 2)
CR K-13 STUO( FULL OUT (POS. 48) FOR 31 MINUTES F0LLOWING SCRAM 3)
TURNOVER ACTIVITIES DURING TRANSIENT 4)
OPERATING LEAVING U1 RX CONSOLE TO HELP ON U2 5)
SCRE PERFORMANCE (TURNOVER DURING EVENT &
"NOT-IN-CHARGE")
6)
OCCURRENCE OF SIMILAR EVENTS AT OTHER CECO STATIONS WILL C0VER EACH o
FORMAT x
CONCERNS (ISSUE) x FACTS x
CONCLUSIONS x
CORRECTIVE ACTIONS OVERLAP.. BEST TO COMPLETE ALL SIX BEFORE QUESTIONS O o
DETAILS CORPORATE OFFICE INVOLVED THROUTHOUT CORP. 0FFICE NOTIFIED THURSDAY. 10/25/84 IN A.M. PSE o
INITIATED WAGNER (PWR OPERATIONS MGR.) AT STATION FRIDAY 10/26/
o WORDEN (BWR OPERATIONS MGR.) AT STATION WEDNESDAY,
~~
o 10/31/84 TURB4( (BWR OPERATIONS STAFF ENGR.) AT STATION o
WEDNESDAY & THURSDAY 10/31 AND 11/1 GALLE INVOLVED TELECON 10/25 AND 10/31 o
MEETING WITH STATION & G.0. ON 11/2 o
2998B/2
E ISSUE:
VALVE 2-305-112 CLOSED ON HCU FOR DRIVE K-13 (WRONG POSITION)
HOT SCRAMMED TESTED K-13 ON 9/18/84 OK (312 FACTS:
VALVE OPEN)
CONDUCTED THOROUGH INVESTIGATION TO DETERMINE HOW VALVE WAS MISPOSITIONED x
ALL WR'S REVIEWED SUBSEQUENT TO REFUELING OUTAGE x
ALL 00S' REQUESTS REVIEWED SUBSEQUENT TO REFUELING OUTAGE x
REVIEWED LOGS FOR HCU ACTIVITY (ACCUMULATOR ALARMS FOUND ON 9/28/84) o DISCUSSED ALARM CLEARING WITH EA'S INVOLVED REVIEWED U1 CORRESPONDING (K-13) HCU MAINT.
REVIEWED U2 HCU MAINT. IN AREA 0F K-13 CORP SECURITY CONSULTED FOR ADVICE CONCLUSIONS:
UNABLE TO DETERMINE ANY ACTIVITY SINCE SCRAM TESTING (9/18) THAT WOULD EXPLAIN MISPOSITIONED 112 VALVE (MISCHIEF CANNOT BE RULED OUT) 2988B/3
Chapter 20 CEK 9597 29 30
. Cr#
- 1. ACCUMULATOR CHARGING WATER R!$ER
- 2. DRIVE-WITHDRAW R15ER 28
=
"l
- 3. ISOLATION VALVE - DRIVE WITHORAW RISER (EP 102) 27 I
['
3
- 4. DRIVE WATER Rl3ER 3.150LAT10N VALVE - ORIVE WATER RISER (EP 1(D) 3 i
m 6.130LAT10ff VALVE -SCRAM DISCHARGE RISER (EPil2) 96 4
5
{
6
- 4. OUTLET $ CRAM VALVE AND ACTUATOR (EP 127) 25 W
- 9. TYPICAL ELECTRICAL CONNECTION h
I
- 10. FIRINCTROJCH A$$EMBLY
+
- 11. MANIFOLO(PART OF PIPING A$$~M8LY) 24 m,
- 32. DIRECTIONAL CONTROL VALVES (4 EACH)(EP 120.121.122.123) 13.150LAT10N VALVE -ACCUMULATOR CHARGINGMTER RISER (EPil3) g
- 14. $ CRAM ACCUM!!LATOR-NITROCEN CYLINDER (EP 123) 9 s
- 15. ACCUMULATOR CA$ PRE 55URE INDICATOR IEP 131)
/
h
- 16. ACCUMULATORINSTRUMENTATION ASSEM3LY 6
- 17. NEEDLE VALVE ACCUMULATOR GAS CHARCl?.G(EP 111) 23
- a. <f, 18.' FRAME
- 19. SCRAM ACCUMULATOR -WATER CYLINDER (EP 123) 10
/
8"#
- 20. hEEOLE VILVE - ACCUMULAIOR WATER CYLINDER DRAIN (EP 101)
- 21. COOLING CHECK VALVE (IN MANIFOLD)
)
I h
- 12. SPEED CONTEL VALVES (2 EACm
- g i F
25.130LATION VALVE - DRIVE INSERT R15ER (EP 101)
- 26. !$0LAT10N VALVE-EXHAUST WATER RISER (EP 105) 22 -
A*
if h
I,i
- 27. EXHAU$T WATER Ri$ER
% ^
hl D
- 12
- 28. DRIVEIN$ERT R13ER
- 23. COOLING WATER RJER 21 -
- 30. $ CRAM Ol3 CHARGE RISER a
3 20 -
f/
3 il w
19 18 %
Q 7
n
'Il g E0 115 - 5 H desut;c Control Unit, Typ; cal hy cU'd Cities 1 Y
20 24
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112 VALVE CLOSED - CONT'D
-~
_/
/
CORR. ACT:,
f IMMEDIATELY WALKED DOWN ALL HCU'S, BOTH' e.
UNITS,.30ENSUREVALVESPOSITIONEDCORRECTLY
. 's p',
SEilEWEDEFFECTSOFSHUT112VALVEWITH EM3/E0'S
~
.I(L-LOO (WIREHCUUPPERVALVESANDPERFORM W
MdfiTHLYrSURVEILLANCEFORSIXNONTHS INITIATED DAILY WALKDOWN OF ALL HCU'S UNTIL LOO (WIRED WILL RELABEL VALVES ON-ACCUM. CHARGING
~
SYSTEM TO ELIMINATE J0SSIBILITY FOR CONFUSION WALKED DOWN D & LS HCU'S t s c.<,
CORP. 0FFICE TO REVIEW LOO (WIRES ON D &.0C'~
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pf E '84 bads
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2988B/LI
. ' ^
s
m ISSUE:
UNIT 1 OPERATOR LEFT RX PANEL FOR 15 MINUTES UNIT 1 STEADY STATE AT APPROX 800 MWE FACTS:
AMBIGU0US CORPORATE & STATION PROCEDURES WRT "AT-THE-CONTROLS" DURING TRANSIENTS CHRON0 LOGY 6:30A.M.01NOPER.WENTTOU2TOHELP (START HPCI) x RESPONDED TO AL ON U1
.x WENT BAOC ONE OTHER TIME TO OBSERVE INSTRUMENTATION x
IN LINE SITE OF U1 PANELS x
REMAINED AWARE OF UI RESPONSIBILITIES 6:45 A.M. UIN OPER. RETURNED TO U1 FOR T.O.
WITH U1D OPER.
x NORMAL T.0.
x UIN OPER. STAYED TO ASSIST ON U2 x
U1D OPER. STAYED AT U1 CONCLUSION:
UNACCEPTABLE OPERATOR DECISION CONSIDERED DISC ACT. - NOT APPROPRIATE i
^
QC INSTRUCTED ALL OPERATING PERSONNEL NOT T0 CORR. ACT:
i LEAVE PENDING FURTHER INSTRUCTIONS (REST BY i
11/9/84)
CLARIFY WRITTEN INSTRUCTIONS TO ALL STATIONS BY 12/15/84 x
NOT ALLOWED EXCEPT IF DIRECT $D BY C.R.
SUPV.
QC RCIC DESIGN WILL BE REEVALUATED 2998B/5
e 4
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t.
QUAD-CITIES CONTROL R00'!
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MISSED K-13 ROD POSITION AFTER SCRAM ISSUE:
CHRON0 LOGY FACTS:
LAPSED TIME TIME MINUTES EVENT 6:41/A 0
RX SCRAM 6:50/A 9
LEVEL UNDER CONTROL 6:54/A 13 U2D OPER. RE0.~0D-7' 7:09/A 28 NUCL ENGR. OBTD.
OD-7 IDENTIFIED K-13 AT P0S. 48 7:10/A 29 RX PRESS UNDER
^
CONTROL (HPCI 0FF)-
7:12/A 31 K13 SCRAMMED FROM BACK PANEL g
J 9
2999B/6
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L' t10-I5-84 1'
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I 7. CONTROL ROD FOSITIONS,' HEW' SC AN 10-25-64 06:54:14 GUAD CITIES iMI
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!I
~T 59' 00. 00.00 00 00-i lc 35 00 -00 00' 00 00 00'
. 06 00
'i' 5'1
- 00- 00
- 00 ~00 00 00 00 +
00 00 02-f!
47 03 00.100 f 00 ' 00 - 00 00 00
- v. 00 00 00 00 k'-
~
143 CO 00 00.
~
00 ' 00.00 00 00 00 OG. 00 00 39-~00 ?00 '00 00 02 00 00' 00 00 00 00- 00 00';00 -00 I;
35 00 :00 00 --00 90 00 02 00 00 00 00 00.00 02 00 31- 00.00 00 00~ 00 '00 '00 00 00 00 00 00 00 00 Os i
-27 :00' '0 0 00 00 00 00 00 00 nn. 00 00 00 00 00 00
=23 00 00 00 00 00 00 00 Oi
.A v 00 00 00 00 00.0C
.19 00
- 00. 00' 0 0 00 ~00 02 uu- 00 00 00 00 00
- 15. 00 00 00' 00 00 00 00 CO 00 00 00 11
.00 00.00 00 00-100 00 00 00 00 00
- 07. '
.'00 - 0 0 00 00 00 00 00 00 00 03 00 00 00 00 00 02 06: 10 14 18-22 E6 30 34 3E: 42 4 50 5 /..:..
-06:57:06 P R Illi - 000D T200 TURD THROTTL STEAll F RESS
--?., - i:5I 0 H-L-.
06:59:21 PF. Il4T. LRL T206 TURB 1ST STAG SHELL FRES-4-F5M H
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MISSED K-13 POSITION
. FACTS (CONT'D)
PERSONNEL ACTIVITIES POST SCRAM U2N OPER:
RX PRESS,iLEVEL CONTROL & RX'S.D.
U2D OPER:
OD-7 INSERT RODS (REACTIVITY CONTROL).
CDN OPER:
RCIC & CONTAINMENT CLG.
CDD OPER:
CENTER DESK SE DEN:
MONITOR CR ACTIVITIES (LEVEL / PRESS)
SCRE D:
STA.
SRM'S IN CORE.
U2 N OPERATOR VERIFIED RX S/D SE'S & SCRE D KNEW RX S/D FULL CORE DISPLAY HAS MULTIPLE LITES DURING SCRAM RX PRESS. 8 LEVEL NOT STABLE FOLLOWING SCRAM U2D OPER. INITIAL ACTION TO PUT ALL RODS IN.
STARTED WITH R0D AT P0S. 02.
2998B/7
=
e R0D K-13 FULL OUT - CONT'D CO,CLUSIONS:
FULL CORE DISPLAY FOLLOWING SCRAM-IS N
CONGESTED WITH INFO.
OPERATING PERSONNEL CONCENTRATED PROPERLY ON MOST IMPORTANT PERAMETERS NEEDING ATTENTION x
RX S/D x
PRESS / LEVEL RXSCRAMPROCEDUREWASFOLLOWEDBYU2Nl0PER.
U2D OPERATOR REVIEWED R0D POSITIONS (0D-7).
MISSED K-13 AT P0S. 48.
WOR (ED ON R0D AT P0S. 02.
MINDSET.
INSTRUCT ALL OPER. PERSONNEL TO MA(E CORR. ACT:
THOROUGH REVIEW 0F OD-7 FOLLOWING SCRAM, i
(D0NE AT QC)
REVIEW OPTIONS FOR OD-7 REVIEW RWM BYPASS PROCEDURES DCR DR ADDRESS FULL CORE DISPLAY CONGESTION O
2998B/8
,m-
,. --.+
ISSUE:
SHIFT TURNOVER SCRE TURNOVER AT 6:25/A'WHILE RX PRESS FACTS:
INCREASING AND RODS COULD NOT BE INSERTED (RWM BLOOO ALL TURNOVERS REVIEWED AS PART OF INVESTIGATION TIME OF ACT. PRIOR ACTIVITY AFTER POSITION TURNOVER TO TURNOVER TURNOVER U 1 OPER.
NIGHTS START. U-2 HPCI 0FFERED HELP ON U-2
^
U-1 CONTROLS DAYS U 2 OPER.
NIGHTS AFTER PRESSURE / LEVEL WENT HOME 7:30 AM DAYS CONTROL RODS U-2 CONTROLS CENT. DEE OPER.
NIGHTS AFTER RCIC/ TORUS CLG WENT HOME CENTER DEM DAYS SHIFT ENGINEER NIGHTS IN CONTROL RM.
ASST. ON 0-2
^
MONITORED U-2 DAYS SCRE NIGHTS IN CONTROL ROOM HELPED UNTIL 6:50 AM STA FOR U-2 DAYS SCRE TURNOVER UNTIMELY CONCLUSIONS:
ALL OTHER TURNOVERS SATISFACTORY WITH EVENT AS EXAMPLE, INSTRUCTED ALL CORR. ACT:
OPERATING PERSONNEL AT OC N01 TO CONDUCT TURNOVERS DURING TRANSIENTS CORP 0FC. WILL MODIFY " CONDUCT OF OPERATIONS" DIRECTIVE 2998B/9-
ISSUE:
SCRE PERFORMANCE 6:25/A SCRE N CONDUCTED ST0 WITH SCRE D F CTS:
DURING UNSTABLE RX CONDITIONS SCRE N HAD DIFFICULTY CONTACTING SE N BY TELEPHONE IN HIS OFFICE SCRE'S a QC UNCOMFORTABLE IN ROLE OF CONTROL ROOM SUPERVISOR DURING TRANSIENTS (LACK 0F EXPERIENCE)
SCRE D DID NOT RECOGNIZE CR K-13 WAS AT P0S.
48 FOLLOWING SCRAM AMBIGUOUS INSTRUCTIONS FOR ALL STATIONS RE.
TRANSITION FROM CONT. RM. SUPV. TO STA ROLE SCRE D OR N DID NOT RECOGNIZE THAT U1 N OPER. LEFT U1 TO HELP ON U2 QUESTIONABLE (WEA() SCRE PERFORMANCE CONCLUSIONS:
SCRE D PERFORMANCE AS STA FOLLOWING SCRAM WAS SATISFACTORY e
2998B/10
r SCRE PERFORMANCE - CONT'D INSTRUCT SE/SCRE'S CORRECTIVE ACTIONS:
1)
LESSONS LEARNED FROM THIS EVENT (ALL STA.:
DONE AT QC) x OPERATOR LEAVE UNIT x
N0 ST0 DURING TRANSIENT x
ALL RODS IN 2)
SCRE NOTIFIES SE IMMEDIATELY GIVEN UNEXPECTED EVENT (a QC FOR NOW:
DONE) 3)
SE MONITOR CR ACTIVITIES NORE CLOSELY (a QC FOR N0W:
DONE) 4)
CORP. OFC. REVIEW APPLICABILITY OF 2) &
- 3) FOR ALL STATIONS 5)
CLARIFY SCRE ROLE SUCH THAT SCRE BECOMES STA FOLLOWING A RX SCRAM (ALL STATIONS)
CORP OFC REVIEW SHIFT ORGANIZATION WITH SPECIAL EMPHASIS ON:
1)
ROLE OF SCRE 2)
NEED FOR SHIFT SUPERINTENDENT e
2998B/11
l a
ISSUE:
GIMILAR-EVENT (S) MIGHT OCCUR AT OTHER STATIONS OPERATOR LEAVING OPERATING UNIT CONTROLS TO HELP ON UNIT EXPERIENCING TRANSIENT SCRE PERFORMANCE STUO( R0D OVERL00(ED FOLLOWING SCRAM HCU ISOLATION VALVES IMPORTANCE (BWR)
CORP. OFC. DIRECTIVES, STATION PROCEDURES, FACTS:
INPO GUIDANCE, AND NRC GUIDANCE LACK CLARITY WITH DEFINITION OF "AT-THE-CONTROLS" DURING TRANSIENT THERE IS DISAGREEMENT AMONGST MGMT. RE ROLE SCRE DURING SCRAM QC HAS HAD MOST DIFFICULTY FILLING SCRE POSITION SCRE AS CONTROL ROOM SUPERVISOR HAS HAD VARIED ACCEPTABILITY ACROSS STATIONS CORP. OFC. JUST COMPLETED SCRE POSITION REVIEW AND MODIFIED POSITION DESCRIPTION C0hCLUSIONS:
THIS EVENT PROVIDES SEVERAL GOOD EXAMP[LES OF LESSONS LEARNED WHICH CAN LEAD TO IMPROVED OVERALL PERFORMANCE OF CONTROL ROOM PERSONNEL
~
2998B/12
o, SIMILAR EVENT (S) MIGHT OCCUR AT OTHER STATIONS (CONT'D)
PSE AND LER WILL BE USED AS TAILGATE SOURCE CORRECTIVE ACTIONS:
FOR ALL CECO STATIONS WILL CONSIDER LOO (WIRE ON HCU CRITICAL VALVES AT ALL CECO STA.
WILL CLARIFY WRITTEN INSTRUCTION RE "AT-THE-CONTROLS" DURING TRANSIENT FOR ALL CECO STA (DIRECTED BY CR SUPV.)
WILL RE-REVIEW SCRE POSITION AT ALL STATIONS (PER SCRE PERF CONCERN)
WILL REVIEW SHIFT ORGANIZATION (PER SCRE PERF. CONCERN) 2998B/13 e