ML20126K045
| ML20126K045 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 12/14/1992 |
| From: | Chaffee A Office of Nuclear Reactor Regulation |
| To: | Grimes B Office of Nuclear Reactor Regulation |
| References | |
| OREM-92-020, OREM-92-20, NUDOCS 9301070009 | |
| Download: ML20126K045 (13) | |
Text
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DEC 141932 8
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 DECEMBER 9, 1992 - BRIEFING 92-20 On December 9, 1992, we conducted an Operating Reactors Events Briefing (92-20) to inform senior managers from offices of the Commission, AEOD, OE, OI, NRR, and regional offices of selected events that occurred since our last briefing on November l' 1992.
Attachment i lists the attendees. presents
~
the significant elements of the discussed event. contains reactor scram statistics for the weeks ending 11/22/92, 11/29/92 and 12/06/92.
No significant events identified for input into the NRC performance were indicator program.
Original SignK bj Alfred E.
Chaffee, Chief Events Assessment Branch Division.of Operating Reactor Support Attachments:
As stated DJ_SJRIBUTION :
Central Files cc w/ attachments:
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T. Murley, NRR-(12G18)
B. Siegel, (PDIII-2)
F. - Miraglia, 1001 (12G18)
J.
Dyer (PDIII-2)
F. Gillespie,-NRR (12 G18 )-
J. Partlow, NRR_(12G18)
S. Varga, NRR (14E4).
J. Calvo, NRR (14A4)
-G.
Lainas, NRR (14H3)-
J. Roe, NRR (13E4) 1 J.
Zwolinski,-NRR (13H24)
M. Virgilio, NRR (13E4)
W. Russell, NRR (12G18)
J. Richardson, NRR (7D26)
A. Thadani, NRR (BE2)
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. Coo, ACRS (P-315)
E. Jordan, AEOD-(MN-3701)
T. Novak, AEOD (MN-9112)
L. Spessard, AEOD_(MN-3701)
K. Brockman, AEOD (MN-220G)'
S.' Rubin, AEOD (MN-5219)
M. Harper, AEOD (MN-9112)
J. Grant,- EDO -(17G21) '
R. Newlin, GPA (2GS)-
A. Dates, SECY-(16G15)
G. Rammling, OCM (16G15)
T. Martin,; Region I W..Kane, Region I C. Hehl, Region I S. Ebneter, Region'II E..Merschoff, Region.II
. B. Davis, Region III E. Greenman, Region-III J..Milhoan, Region IV
' B. Beach,-Region IV J.B. Martin,7 Region V-1K. Perkins, Region V-
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-ATTACHMENT 1 LIST OF ATTENDEES OPERATING REACTORS EVENTS FULL BRIEFING (92-20)
DECEMBER 9, 1992 i-NAME OFFICE NAME OFFICE A.
CHAFFEE NRR C.
SIEGEL-NRR T. GREENE NRR B.' GRIMES NRR K. GRAY NRR T. MURLEY NRR-T. KOSHY NRR C.
THOMAS NRR E.
ENG NRR V. BENAROYA AEOD J. - HANNON NRR -
T.'SHEDLOSKY OCM/IS G.
MARCUS NRR
- J.
JANG REGION I S.
BAJWA NRR R.
FORTUNA OI W.
BELL NRR T..ULSES NRR J. MUNRO NRR TELEPHONE ATTENDANCE (AT ROLL CALL)
Recions Resident Inspectors l
Region I Region II Region III Region IV AIT Team Leaders
-Misc.
P. Hiland L
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ATTACHMENT 2 OPERATING REACTORS EVENTS BRIEFING 92-20 E'lfNTS ASSES.SHENT BRANCH LOCATION:
10 B11, WHITE FLINT WEDHESAY, DECEMBER 9, 1992, 11:00 A.M.
DRESDEN 2 FAILURE TO REPORT AND DOCUMENT CONTROL R0D MOVEMENT ERROR
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92-20 d.
DRESDEN, UNIT 2 FAILURE TO REPORT AND DOCUMENT CONTROL ROD MOVEMENT ERROR SEPTEMBER 18, 1992 l
l ERDALEM WHILE PERFORMING CONTROL R0D MOVEMENTS T0' LOWER THE FLOW-1 CONTROL LINE, THE REACTOR OPERATOR MISPOSITIONEDLA CONTROL-R0D.
THE PROBLEM WAS. COMPOUNDED:BY SUBSEQUENT R0D l
MOVEMENT WITHOUT FOLLOWING PROCEDURES OR AUTHORIZATION.
THE FIVE INDIVIDUALS INVOLVED APPARENTLY DECIDED NOT TO REPORT, LOG, OR DISCUSS THIS INCIDENT WITH ANYONE.
CAUSE THE CAUSE OF THE MISPOSITIONED CONTROL-R0D WAS OPERATOR ERROR.
SUBSEQUENT ERRORS -WERE THE RESULTL OF LTHE-INDIVIDUALS 1 INVOLVED NOT FOLLOWING DRESDEN OPERATING-ABNORMAL PROCEDURES FOR MISPOSITIONED: CONTROL RODS.
-THIS RESULTED IN NUMEROUS PROCEDURAL DEVIATIONS.
SAFETY SIGNIFICANCE 1HE SAFETY SIGNIFICANCE'0F;THE MISPOSITIONED CONTROL 1 RODS IS MINIMAL.
HOWEVER, THE SAFETY SIGNIFICANCE OFLTHE1 EVENT AS A WHOLE, REVOLVES AROUND ISSUESLOF HONESTY AND.
INTEGRITY ON THE.PART OF THE OPERATIONAL STAFF.
CONTACTS:'
P.- HILAND,. RIII AIT:
H0_
s T. GREENE, NRR/ DORS-SIGEVENT:
IRQ
REFERENCES:
PN39262 &.PN39262A a
.-. m...-
j 2-92-20 DRESDEN, UNIT 2 DISCUSSION 0
ON SEPTEMBER 18, 1992, AN OPERATOR WAS MOVING CONTROL RODS TO LOWER THE FLOW CONTROL LINE IN ACCORDANCE WITH APPROVED ROD INSERTION TNSTRUCTIONS.
POWER LEVEL WAS l
APPROXIMATELY 85%.
t 0
THE OPERATOR MISTAKENLY INSERTED A PERIPHERAL CONTROL
- R0D NOT AUTHORIZED IN THE ROD INSERTION INSTRUCTION FROM POSITION 48 (FULL OUT) TO POSITION 36.
THE ROD WAS MOVED WITHOUT OBTAINING A SECOND INDEPENDENT VERIFICATION PRIOR TO MOVEMENT.
O THE QUALIFIED NUCLEAR ENGINEER- (QNE) AND REACTOR OPERATOR RECOGNIZED THE MISPOSITIONED ROD.
HOWEVER,.
H THE ONE DIRECTED THE OPERATOR TO INSERT ADDITIONAL CONTROL RODS CONTRARY TO DRESDEN OPERATING-ABNORMAL PROCEDURES.
0 THE QNE WROTE SPECIAL INSTRUCTIONS TO INSERT ADDITIONAL RODS INCLUDING THE MISPOSITIONED ROD.
THESE NEW INSTRUCTIONS INCLUDED-RODS NOT IN THE ORIGINAL R0D INSERTION INSTRUCTIONS.
O THE ADDITIONAL R0D MOVEMENTS WERE PERFORMED WITHOUT THE L
KNOWLEDGE-OR-CONCURRENCE 0F THE-SHIFT CONTROL ROOM L
ENGINEER (SCRE).
THE SCRE CONCURRED-0N THE SPECIAL INSTRUCTION AFTER-THE FACT.
. 0 THE FIVE-INDIVIDUALS INVOLVED - THE SCRE, THE REACTOR OPERATOR, THE ONE, AND TWO NUCLEAR ENGINEERS IN-TRAINING - APPARENTLY DECIDED NOT-TO REPORT, LOG, OR L
DISCUSS THIS INCIDENT WITH ANYONE.
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DRESDEN, UNIT 2 92-20 0
MANAGEMENT BECAME AWARE OF THE INCIDENT ON NOVEMBER 23 AND INITIATED AN INVESTIGATION ON NOVEMBER 24.
EDLLQWME 0
NRC SENT A SPECIAL INVESTIGATION / INSPECTION TEAM WITH A CHARTER TO THE SITE ON NOVEMBER 30, 1992.
0 THERE WERE ABOUT 10 TO 12 PROCEDURES VIOLATIONS.
O THIS INCIDENT IS NOT A REPORTABLE EVENT.
O FOUR OUT OF THE FIVE INDIVIDUALS INVOLVED IN THE INCIDENT WERE TERMINATED FROM EMPLOYMENT WITH COMMONWEALTH EDISON.
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4 ATTACHMENT 3 0
0 REACTOR SCRAM
SUMMARY
WEEK ENDING 11/22/92 1.
PLANTSPECIFICDATA(1)
DATE
$1TE UNIT POWER SIGNAL CAUSE COMPL1- (3 hTD YTD YTD CATIONS AB0VE BELOW
-TOTAL 15%
15%
11/16/92 LASALLE 2
100 A
PERSONNEL NO 2
0 2
11/18/92 FERMI 2
98 M
PERSONNEL NO 2
1 3
11/20/92 MILLSTONE 3
100 A
EQUIPMENT N0 3
0 3
11/22/92 CLINTON 1
75 M
EQUIPMENT N0 3
0 3
REACTOR SCRAM
SUMMARY
WEEK ENDING 11/29/92 1.
PLANT SPECIFIC DATA (I)
DATE SITE UNIT POWER SIGNAL-CAUSE COMPL1-(3)YTD YTD YTD CATIONS ABOVE BELOW TOTAL 15%-
15%
~ 11/24/92 RIVER BEND 1
95 A
EQUIPMENT NO 4
0 4
11/24/92 CALVERT CLIFFS 1
100 A
EQUIPMENT NO 1
0' 1
11/27/92 HATCH ~
2 70 A
EQUIPMENT N0 3
0 3~
11/27/92 SIABROOK 1
100.
A EQUIPMENT N0' 1
1 2
II. COMPARISON Of WEEKLY STATISTICS WITH INDUSTRY AVERAGES SCRAMS FOR WEEK ENDING 11/22/92 NUMBER 1992 1991 1990 1989 1988 0F WEEKLY WEEKLY WEEKLY WEEKLY WEEKLY SCRAM CAUSE SCRAMS AVEPAGE AVERAGE AVERAGE AVERAGE AVERAGE Siin POWER GREATER THAN 15%
EQUIPMENT RELATED 2
i.
f.9 3.4 3.1 3.0 PERSONNEL RELATED (2) 2 0,8 0.6 0.5 1.0 1.0 OTHER(4) 0 0.0 0.0 0.0 0.1 0.4 Subtotal 4
3.4 7.5 3.9 4.2 4.4 POWER LESS THAN 15%
EQUIPMENT RELATED 0
0.5 0.3 0.4 0.3 0.6 PERSONNEL RELATED (2) 0 0.2 0.2 0.1 0.3 0.4 OTHER (4) 0 0.0 0.0 0.0 0.0 0.2 Subtotal 0
0.7 0.5 0.5 0.6 1.2' TOTAL 4
4.1 4.0 4.4 4.8 5.6 MANUAL VS AUTO SCRAMS 1992 1991 1990 1989 1988 NO. Of WEEKLY WEEKLY WEEKLY-WEEKLY WEEKLY-TYPE SCRAMS AVERAGE AVERAGE AVERAGE AVERAGE AVERAGE (YTD)
MANUAL SCRAMS 2
1.0-0.7 1.2 0.9 1.1:
3.1 3.3 3.2 3.9 4.5
II. COMPARISON OF WEEKLY STATISTICS WITH INDUSTRY AVERAGES SCRAMS FOR WEEK ENDING 11/29/92 NUMBER 1992 1991 1990 1989 1988 0F WEEKLY WEEKLY WEEKLY WEEKLY WEEKLY SCRAM CAVSE SCRAMS AVERAGE AVERAGE AVERAGE AVERAGE AVERAGE (YTD)
POWER GREATER THAN 15%
EQVIPMENT RELATED 4
2.6 2.9 3.4 3.1 3.0 PERSONNEL RELATED (2) 0 0.8 0.6 0.5 1.0 1.0 OTHER (4) 0 0.0 0.0 0.0 0.1 0.4 Subtotal 4
3.4 3.5 3.9 4.2 4.4 POWER LESS THAN 15%
EQUIPMENT RELATED 0
0.5 0.3 0.4 0.3 0.6 PERSONNELRELATED(2) 0 0.2 0.2 0.1 0.3 0.4 OTHER (4)
G 0.0 0.0 0.0 0.0 0.2 Subtotal 0
0.7 0.5 0.5 0.6 1.2 TOTAL 4
4.1 4.0 4.4 4.8 5.6 HANVAL VS AUTO SCRAMS l
1992 1991 1990 1989 1988 l
NO. OF WEEKLY WEEKLY WEEKLY WEEKLY WEEKLY TYPE SCRAMS AVERAGE AVERAGE AVERAGE AVERAGE AVERAGE l
(YTD)
HANUAL SCRAMS 0
1.0 0.7 1.2 0.9 1.1 AUTOMATIC SCRAMS 4
3.1 3.3 3.2 3.9 4.5 l
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0 8
9 REACTOR SCRAM
SUMMARY
WEEK ENDING 12/06/92 1.
PLANT SPECIFIC DATA (1)
DATE SITE UNIT POWER SIGNAL CAUSE COMPLI-(3)YTD YTD YTD CATIONS AB0VE-BELOW-TOTAL 15%
15%
12/03/92 HILLSTONE 1
100 A
PERSONNEL NO 1
0 1
12/03/92 HOPE CREEK 1
100 M
PERSONNEL NO 1
0 1
12/04/92-LIMERICK 2
77 M
PERSONNEL N0 1
0 1
i
- 11. COMPARISON OF WEEKLY STATISTICS WITH INDUSTRY AVERAGES SCRAMS FOR WEEK ENDING 12/06/92 NUMBER 1992 1991 1990 1989 1988 0F WEEKLY WEEKLY WEEKLY WEEKLY WEEKLY SCRAM CAUSE SCRAMS AVERAGE AVERAGE AVERAGE AVERAGE AVERAGE (YTD)
POWER GREATER THAN 15%
EQUIPMENT RELATED 0
2.6 2.9 3.4 3.1 3.0 PERSONNEL RELATED (2) 3 0.8 0.6 0.5 1.0 1.0 OTHER (4) 0 0.0 0.0 0.0 0.1 0.4 Subtotal 3
3.4 3.5 3.9 4.2 4.4 POWER LESS THAN 15%
EQUIPMENT RELATED 0
0.5 0.3
.0.4 0.3 0.6 PERSONNEL RELATED (2) 0 0.2 0.2 0.1 0.3 0.4 OTHER (4) 0 0.0 0.0 0.0 0.0 0.2 I
Subtotal 0
0.7 0.5 0.5 0.6 1.2 TOTAL 3
4.1 4.0 4.4 4.8 5.6 MANUAL VS AUTO SCRAMS 1992 1991 1990 1989 1988 NO. OF WEEKLY WEEKLY WEEKLY WEEKLY WEEKLY TYPE SCRAMS AVERAGE AVERAGE AVERAGE AVERAGE-AVERAGE (YTD)
MANUAL SCRAMS 2
1.0 0.7 1.2 0.9 1.1 AUTOMATIC SCRAMS 1
3.1 3.3 3.2 3.9 4.5
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g..
m.
y
80111 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.
2.
PERSONNEL RELATED PROBLEMS INCLUDE HVHAN 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 CAUSL.
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 --(YTD 12/06/92)-- 201
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