ML20141K389

Summary of Operating Reactor Events Meeting 86-01 on 860106 Re Events Occurring Since 851223 Meeting.Attendee List, Events,Significant Elements of Events & Completion Dates for Assignments Encl

ML20141K389
Person / Time
Site:	Hatch, Peach Bottom, Crystal River, Rancho Seco, 05000000
Issue date:	01/09/1986
From:	Holahan G Office of Nuclear Reactor Regulation
To:	Harold Denton Office of Nuclear Reactor Regulation
References
NUDOCS 8601220484
Download: ML20141K389 (26)

Text

n JANS 1995 MEMORANDUM FOR: Harold R. Denton, Director Office of Nuclear Reactor Regulation FROM: Gary M. Holahan, Director Operating Reactors Assessment Staff

SUMMARY

OF THE OPERATING REACTORS EVENTS MEETING ON January 6, 1986 - MEETING 86-01 On January 6, 1986, an Operating Reactor Events meeting (86-01) was held to brief the Office Director, the Division Directors and their representatives on events which occurred since our last meeting on December 23, 1985. The list of attendees is included as Enclosure 1.

• The events discussed and the significant elements of these events are presented in Enclosure 2. In addition, the assignment of follow-up review responsibility was discussed. The assignments made durino this meeting and the status of previous assignments are presented in Enclosure 3.

Completion dates have been assigned for items in Enclosure 3. Each assignee should review Enclosure 3 with regard to their respective responsibilities.

Note that several assignees are approaching the due date. Please be responsive and advise ORAS (G. Tarnoff, x29526) if the target completion date cannot be met.

OriginPl Si%fM OY 31lI Gary M. Holahan, Director Operating Reactors Assessment Staff

Enclosures:

As stated cc w/ enc 1:

See next page DISTRIRUTION iCentral Files NRC PDR ORAS Reading ORAS Members ORA D

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..- JAN 9 1903 MEMORANDUM FOR: Harold R. Denton, Director Office of Nuclear Reactor Regulation FROM: Gary M. Holahan, Director Operating Reactors Assessment Staff

SUMMARY

OF THE OPERATING REACTORS EVENTS MEETING ON January 6, 1986 - MEETING 86-01 On January 6,19P6, an Operating Reactor Events meeting (86-01) was held to brief the Office Director, the Division Directors and their representatives on events which occurred since our last meeting on December 23, 1985. The list of attendees is included as Encle:ure 1.

The events discussed and the significant elements of these events are presented in Enclosure 2. In addition, the assignment of follow-up review responsibility was discussed. The assignments made during this meeting and the status of previous assignments are presented in Enclosure 3.

Completion dates have been assigned for items in Enclosure 3. Eachassignee should review Enclosure 3 with regard to their respective responsibilities.

Note that several assignees are approaching the due date. Please be responsive and advise ORAS (D. Tarnoff, x29526) if the target completion date cannot be met.

-)) (

o w(\

)

ne h:o Gary MM olahan, Director Operating Reactors Assessment Staff

Enclosures:

As stated cc w/ encl:

See next page

+ .,

+

Harold R. Denton -?-

cc: D. Eisenhut H. Silver J. Taylor B. Mozafari C. Heltemes G. Gears T. Murley, Reg. I J. Stolz J. Nelson Grace, Reg. II G. Rivenbark J. Keppler, Reg. III D. Muller R. D. Martin, Reg. IV S. Miner

• J. B. Martin, Reg. V R. Starostecki, Reg. I R. Walker, Reg. II C. Norelius, Reg. !!!

E. Johnson, Reg. IV D. Kirsch, Reg. V H. Thompson F. Miraglia R. Bernero T. Spois W. Russell T. Novak F. Schroeder W. Houston B. Sheron D. Zierann J. Knight D. Crutchfield j G. Lainas V. Bcnaroya W. Regan

) D. Vassallo l E. Jordan 3 E. Rossi

! R. Baer E. Weiss R. Hernan K. Seyfrit i

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ENCLOSURE 1

, OPERATING REACTORS EVENTS BRIEFING 86-01 1

JANUARY 6, 1986 LIST OF ATTENDEES G. Holahan NRR/0 RAS S. Miner NRR/PWR-B R. Singh IE/DEPER E. Rossi IE/DEPER/EAB J. Stone IE/QAVT J. Stolz NRR/PWR-0 K. Mitchell NRR/PWR-A 0. Humanansky OCM H. Silver NRR/PWR-B F. Schroeder NRR/PWR-B D. Vassallo F0B/ DBL T. Speis NRR/PWR-B W. Regan F08/0PL-B B. Sheron NRR/DSRO l V. Benaioya NRR/PWR-A R. Bernero NRR/ DBL R. Baer IE/DEPER 0. Tarnoff NRR/0 RAS S. Black NRR/TOSB M. Virgillo NRR/ORAS W. Swenson NRR/ORAS G. Gears NRR/ DBL L. Velly NRR/0 RAS G. Rivenbark NRR/ DBL G. Kalman NRR K. Eccleston NRR/TOSB R. Frahn NRR/DSR0 J. Knight NRR/PWR-A R. Wright NRR/0PLB F. Ashe AE00/ROA8

0. Zukor AE00/R0AB K. Seyfrit AE00/ROAB B. Mozafari NPR.PWR-B R. Weller NRR/PWR-8 W. Paulson NRR/PWR-B T. Rotella NRR/ DBL

, E. Jordan IF S. Newberry NRR/ORAS l

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ENCLOSURE 2 OPERATING PEACTORS EVENT BRIEFING 86-01 JANUARY 6, 1986

]

RANCHO SEC0 REACTOR TRIP AND UNCONTROLLED C00LDOWN CRYSTAL RIVER UNIT 3 PEACTOR TRIP PEACH BOTTOM UNIT 2 REACTOR TRIP AND WATER HAMMER i HATCH UNIT 2 LOSS OF DIESELS A .

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)

RANCHO SECn QEACTOR TRIP AND UNCONTROLLED C00LDnwN DECEMBER 26, 19P,5_- (S MINER, NRR)

] PROBLEM:

! ICS POWER FAILURE RESULTED IN REACTOR TRIP AND PPIMARY SYSTEM j OVERC00 LING EVENT SIGNIFICANCE:

ICS FAILURE INITIATED AF OVERC00 LING EVENT TilAT EXCEEDED

, RANCHO SECO PTS LIMITS I -

NO SPECIFIC PROCEDlJRES OR TRAINING FOR ICS FAILURES

- MAY BE GENERIC TO BR,W DESIGNED PLANTS DISCUSSION:

PLANT AT 76% FP&P LOSS OF ICS POWER (0413)

STARTUP AND MFW VALVES CLOSED TO 50% DEMAND; FFWP SPEED PEDllCED:

l ADVs AND TBVs AND 1 SET OF AF'1 FLn'4 CONTROL VALVES OPEPF0 TO l 507, DEMAND AFW SYSTEM STARTED AUTOMATICALLY ON LOW MFWP DISCHARGE PRESSURE j -

REACTOR TRIPPED ON HIGH PRESSURE MFPs TRIPPED MANUALLY HIGH AFW FLOW VIA ICS CONTROLLED VALVES  !

RCS PRESSlJRE DECREASED TO 1600 PSIG SFAS INITIATED i MANUALLY CLOSED SFAS CONTROLLED AFW VALVES PRESSURIZER LEVEL WENT OFF SCALE LOW SG PRESSijRE DECREASED TO 500 PSIG - CONDENSATE PUMPS BEGIN TO FEED THE SG's PLANT EXCEEDS BP.W PTS LIMITS RCS 1064 PSIG, < 50n*F OPERATOR THROTTLES HPI INJECTION FLOW AT SG PRESSllRE 435 PSIG MAIN STEAM LINE Fall.URE LOGIC Cl.0 SED MFW VALVES - CONDENSATE PUMP FEED STOPPED 1 ADVs AND TBVS MANllALLY ISOLATED l OPERATORS EXPERIENCE DIFFICULTY IN CLOSING ICS CONTROLLED l AFW VALVES l -

"A" 0TSG FULL TO TOP 0F THE SHROUD, WATER SPil. LED INTO STEAM ANNULUS

_ - . _ . _ - - - - - - - - . _ _ - . ..-.0

• I 1

RCS PEAKS SECOND TIME: 1616 PSIG AND 42?'F AFW FLOW TERMINATED T0 "B" 0TSG MAKEUP TANK LEVEL HIGH-CLOSED "A" LOOP BWST SUCTION VALVE ICS POWER RESTORED - CLOSED AFW VALVES, "A" OTSG LEVEL DECREASED BELOW STEAM SHROUD SHUTDOWN HPI PUMPS - MAKEUP PUMP ST!LL RUNNit!G SR0 COLLAPSES IN FRONT OF CONTROL PANEL MAKEUP PUMP FAILED - APPR0XIMATELY 400 GALLONS SP!LLED OUT PUMP SEALS RESTORED MFW FLOW PATH FOLLOW-UP:

CONFIPMATORY ACTION LETTERS ISSUE 0 DECEMBER 27, 1085, AUGMENTED INSPECTION TEAM (AIT) SENT TO SITE, AL CHAFFEE (REGION V) TEAM LEADER DECEMBER 31, 1985, AIT CONVERTED TO IIT,

{ FRED HEBDON (AE0D) TEAM LEADER MEETING WITH B8W REGULATORY RESPONSE GROUP SCHEDULED FOR JANUARY 8, 1986 i

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l Rev. 2 01/05/86 INCIDENT INVESTIGATION TEAM PRELIMINARY SEQUENCE OF EVENTS INITIAL PLANT CONDITIONS

- Unit operating at steady state power of 76% (710 MW(e)].

- Reactor Coolant System (RCS) average temperature is 582 F.

- RCS pressure is 2150 psig.

- This plant does not have Main Steam Isolation Valves (MSIVs).

- The plant had started up on December 24, 1985 following an outage of 2 days.

- Integrated Control System (ICS) in full automatic.

- The Bailey computer was out of service (one of the plant's two systemsintheControlRoom).

Consequently, the Bailey post-trip review, Bailey alams printout, and Bailey inputs to the Interim Data Aquisition and Display System (IDADS) are not available from sources other than the Bailey computer are available IDADS inputs

, TIME DESCRIPTION OF EVENT DATA SOURCE Transient initiation 04:13:47

" Loss of ICS or Fan Power" Annunciator Alarm. IDADS Print loss of ICS is caused by the simultaneous de- out energizin supplies.g of all redundant ICS DC power ICS demand signals go to midscale.

(The ICS works on +/- 10 volt scale, with zero

. volts being 50% demand). The startup and Main Feedwater (MFW) valves close to 50% because of this decrease in demand signal. The loss of <

decrease to the minimum speed of 2500 RPM.ICS With the plant initially at 76% power, this reduction in MFW flow increases RCS pressure.

The loss of ICS DC power also sends demand signals 1 to one of two sets of Auxiliary Feedwater (AFW) flow control valves I the Atmospheric Dump Valves (ADi/s) and the Turbine Bypa,ss Valves (TBVs) to open to 50% demand (6ute:

l The plant has two parallel sets of AFW valves.

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d 2

1 1 One set is controlled by the ICS and one set i controlled by the Safety Features Actuatior Sg. tem).

Operator / System Response to the Loss of ICS Power 04:13:7 Control room operators notice NFW flow decreasing rapidly. Also, they notice RCS operator pressure increasing. Operators open the Statement pressurizer spray valve in an attempt to stop the RCS pressure increase.

1 Due to the rapid overheating of the RCS by the reduction in MFW flow (it appears that MFW flow

actually decreased to zero), the actuation of i

pressurizer spray is not sufficient to reverse the RCS pressure increase.

i 04:14:01 The reduction in MFW pump speed causes a low 10 ADS

! MFW pump discharge pressure of less than 850 psig which automatically starts the Print motor driven AFW pump. out

! 04:14:03 Reactor trips on high RCS pressure. The turbine trip is also initiated by the reactor trip. A 10 ADS Print out Control Room operator closes the pressurizer spray valve.

04:14:04 Peak RCS pressure of 2298 psig. Several Main Steam 3

j Safety Valves are believed to have lifted and 1 >S Print reseated early in the event.

out 04:14:06 AFW dual drive (i.e. steam & electric) pump IDADS autostarts on low MFW pump discharge pressure (850 psig). Print t out This AFW pump is steam-driven throughout this transient. ~

04:14:06 Peak RCS hot leg temperature of 606.5 F.

' IDADS Print 1

out Operator / Systems Response to the Plant Trip and Overcooling 04:14:7 Immediately upon reactor trip, man The Technical Support Center (TSC)y fireactuation alarms, Operator i spray alam, the seismic trouble alarm, and Spent Fuel Pool Statement (SFP) temperature high alams are received. The - -

significance of this is still being assessed. ~-

The operators perfom the actions of the Fmergen u P"--

1

.s..

+ -- ' * ". , F 01 (%ec Wr T. "p l ..ns include reducing RCS letdown flow.

l

3 Operators then proceed with Emergency Procedures section E.02 (Vital System Status L

Verification).

04:14:11 AFW flow begins to both Once Through Steam Generators IDADS Print (OTSGs) through the ICS-controlled AFW Flow Control {

out '

Valve.

5 04:14:25 Operators note pressurizer level decreasing, Operator and fully open the "A" injection valve for more Statement makeup flow to RCS. ,

IDADS Print out 04:14:30 The loss of ICS power also results in loss of Operator manual (i.e. hand) control of ICS controlled Statement valves from the Control Room. Therefore, non-licensed operators are sent to close the TBVs, ADYs, and AFW flow control valves. (Note: The ADVs and TBYs could have been shut from the Remote Shut-down Panel. However, the operators failed to remember this fact).

The operators recognize the beginning of an overcooling transient due to the open startup and main MFW valves, the half open TBVs and ADVs the open AFW flow control valves, along with MFW speed remaining at around 2500 RPM.

04:14:48 Makeup tank (MUT) level decreasing rapidly. Operators Operator

.: open the Borated Water Storage Tank (BWST) suction Statement valve on the "A" side to provide an additional source of makeup water.

04:15:04 Operators start the "B" HPI pump to increase IDADS Print makeup flow to the RCS from the BWST. out 04:16:02 Operators trip both MFW pumps. IDADS Print out/

MFW flow indication on the Control Room strip Operator charts indicates about 3.5 million pounds Statement per hour. However, this MFW flow indication passes through modules powered by the ICS and,

therefore, the loss of ICS power causes this indicator fail to midscale. The actual MFW flow rate indicated by the IDADS print out decreased to zero upon reactor trip and does not begin increasing again before the reactor operators trip the MFW pumps. The actual MFW flow rate .

remained at zero due to the increased i

pressure in both OTSGs and the low speed

'~.1r4 to bnth M N pumps.

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4 AFW flow is greater than 1000 gpm to each OTSG. IDADS Print out 04:16:7 An operator isolates pegging steam, which is used Operator to heat MFW during low power operation. The Statement operator isolates it because he believes that a MFW heater relief valve may have lifted.

04:16:57 RCS pressure has decreased to 1600 psig. Pressur- IDADS izer level is 15 inches. The Safety Features Print Actuation System (SFAS) automatically initiates. out A, B, C and D HPI injection valves open to pre-detemined positions. Selected SFAS equipment, including the motor-driven AFW pump, automatically sheds off the vital busses and sequence loading of SFAS equipment begins.

AFW (SFAS-controlled) valves travel full open. "A" & "B" Low Pressure Injection / Decay Heat Removal (LPI/DHR) pumps autostart in the recirculation mode. Diesel generators autostart but do not close onto the vital busses as there has been no loss of power to the vital busses. SFAS also actuates containment (i.e. reactor) building isolation. This actuation isolates suction to the containment building radiation monitors, which subsequently causes one of the associated sample pumps to overheat and damage its seals.

04:16:59 "A" HPI pump autostarts on SFAS signal. IDADS Print out Operator / Systems Response to SFAS Initiation 04:17:10(?) Operrtor overrides SFAS signal to the AFW Operator (SFAS-controlled) flow control valves and closes Statement /

them. IDADS Print out 04:17:15 A" & "B" Control Room / Technical Support Center IDADS Print (CR/TSC) Essential Heating Ventilation and out/

Air Conditioning (HVAC) units start on the Operator SFAS signal. This significantly increases the Statement noise level in the Control Room.

04:17:27 Motor-driven AFW pump automatically 'IDADS Print sequences back on its vital bus and restarts. out The dual-drive AFW pump has been running continuously and powered by steam since it initially started. - -

04:18:58 RCS temperature decreases below 500 F. IDADS Print out  ;

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04:19:15 Operators secure "A" CR/TSC Essential HVAC to IDADS Print reduce the noise level in the control room. out/

Operator Statement 04:20:00 Pressurizer level offscale low. Subcooling IDADS Print margin is 85 F and increasing. out 04:20:+ Shift Supervisor sends a computer technician Operators to check the ICS power supply. Statement The technician reports that all four ICS 24 VDC power supplies are de-energized. The Automatic Bus Transfer (ABT) has not transferred and is still on the "C" bus (vital bus) which is still energized. It is later detemined that the' ICS "J" bus loads (non-vital bus) had earlier been connected to the "F" power bus. The "F" power bus (non-vital) also supplies power to the TSC Fire System (which alamed upon reactor trip). Also, portions of the security lighting which is powered by the 2C bus which powers the F bus was momentarily I

out about the time of the reactor trip.

l This is the first of four individuals who indpedndently check the ICS power supply cabinets and do not note that the power supply switches (51 and S2) are open.

,. 04:20:20 OTSG pressures have decreased to 500 psig. IDADS Print out At this pressure the running condensate pumps begin to supply MFW to the OTSGs through the idle MFW pumps. This adds approximately 1000 gpm of flow to each OTSG.

04:21:25 Minimum RCS pressure of 1064 psig is reached. IDADS Print out 04:22 The plant exceeds the B&W recomended pressure / IDADS Print temperature limits for pressurized themal shock out (PTS) of the reactor vessel (i.e., the PTS region).

The nil ductility temperature limits in the Technical Specifications are not violated during this event.

04:22 Operator initially throttles HPI injection flow (Note: RCS pressure is beginning to increase, 'L but pressurizer level is still off-scale low). -

1 04:22:50 OTSG pressures have decreased to 435 reig. IDADS Print ou t.

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Main Steam Line Failure Logic actuates which closes the startup and main MFW valves.

MFW flow from the condensate pumps is stopped.

04:23 ADV and TBV isolation valves shut locally Operator (i.e., by handwheels) by operators. Statement j 04:23:10 Non-licensed operator attem9ts to close "B" AFW IDADS Print (ICS-controlled) control valve using the valve out/

handwheel. The valve is parlially closed by the Operator operator, however, much of the flow appears to Statement have been merely redirected to the "A" AFW valve.

The operator thought he had completely IDADS Print closed the valve at this point. AFW out flow to the "B" OTSG, however, has decreased by only about 60%.

04:25:30 Operator opens the HPI pump SFAS-controlled recircu- IDADS Print l 1ation valves, opening the recirculation path to the out makeup tank, to prevent overheating the pumps when flow is subsequently further throttled.

However, the discharge valve from the Makeup Tank is still closed at this time.

04:26:15 CR/TSC Essential HVAC train "B" is secured ido Operator further reduce noise levels in the Control Room. Statement

' Operator notes that the signal to start it in the high temperature /high radiation level mode was present. The significance of this fact is still being assessed.

04:26:'l Operator attempts to close "A" AFW (ICS- IDADS Print controlled) control valve using the valve out handwheel.

04:26:22 "A" AFW valve closed. However, much of the flow Operator i

appears to have been merely redirected to the Statement  :

partially open "B" AFW valve. Operator believes the "A" AFW valve is only 80% closed and leaves to locate a valve wrench.

04:26:47 Pressurizer level is back on scale and increasing. IDADS Print Subcooling margin is 170 F. Operators throttle out l HPI injection valves to decrease the rapid increase of reactor pressure.

04:28:00 Makeup tank level offscale high. Pressure Relief IDADSPrint Valve opens and discharges to the Flash Tank. ,out 04:28:00 Operators mar.'rtly s**o "C" "CP per core lift IDADS Print restr.cti. ... . ..p. ire that the out

7 RCP be tripped when RCS temperature decreased to 500 F at 04:18. RCS temperature is now 490 F.

04:28:59 Operators stop "A" HPI pump. IDADS Print out 04:29:40 Non-licensed operator uses valve wrench on "A" Operator AFW (ICS-controlled) flow control valve. Manual Statement portion of valve operator is apparently damaged.

The valve suddenly fails to the open position.

Operator calls Control Room and is told to close the "A" AFW manual isolation valve.

04:29:40 RCS pressure peaks a second time at 1616 psig. RCS IDADS Print temperature is 422 F. out 04:29:45 Operator closes "C" & "D" HP! injection valves IDADS Print to reduce the repressurization while temperature out is still decreasing.

04:30 Shift supervisor declares Unusual Event. The Operator Senior Control Room Operator notifies State Statement and County agencies.

04:30:30 Operators start depressurizing RCS, in an attempt to Operator return to condition outside PTS region, using Statement &

normal pressurizer spray. RC Pressure Plot

... 04:33:20 Another non-licensed operator arrives at the "B" AFW Operator control valve and closes it all the way. AFW Statement &

to the "B" OTSG is now stopped; however, some IDADS Print of this flow may have been merely diverted to out ,

the "A" OTSG.

{

04:33:40 The "A" OTSG is full to the top of the steam IDADS Print shroud and begins to spill water into the steam {

out '

annulus and into the main steam lines. At this time the AFW flow to the "A" OTSG is in excess of 1300 GPM.

l 04:35 Operators close the "A" Loop BWST suction valve Operators in an attempt to miti I the makeup tank (MUT) gate the high level in Statements i

. However, the discharge l valve from the MUT is still shut. (Note: on the l simulator, shutting the BWST suction valve automat-ically opens the dischar0e valve from the MUT.

This is not the case in the plant). This action . .

isolates the suction to the makeup pump, the "A" t HPI, and the "A" LPI/DHR pump. .

04:36 Non-licensed operator attempts to close the Operator

"" AFu winut.1 isolation valve but it will Si.dtement not move, even with valve wrench.

.. - -. __ :, s - - - . - - - - . - _ -

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04:39:00 RCS subcooling margin reaches peak of 201 F IDADS Print and begins to decline. (RCS temperature = 390 F, out RCS pressure = 1430 psig) This is approximately 800 psi into the PTS region.

04:40 An SRO discovers that the switches (51 and S2) Operators to the ICS DC power supplies are tripped to the Statement /

off position. ICS power is restored by closing IDADS Print switches S1 and 52 in ICS cabinet 3. (Note: out the ICS DC Power Supplies are located in ICS cabinet 2).

Operator / Systems Response to Restoration of ICS Power Initially the ADVs TBVs and AFW valves receive a demand signal to go fully open when power is restored. However, the isolation valves for all but the "A" AFW valve had been closed. The Control Room Operators innediately switch to manual (i.e., hand) control and shut the valves. '

All AFW flow to both OTSGs has ceased. RCS begins to heat up. Lowest RCS temperature of 386 F was reached and at this time RC pressure (1413 psig) is being reduced to achieve conditions outside the PTS region. The plant has cooled down 180 F in 24 minutes.

! ,, 04:41:00 Operator calls Control Room and reports Operator that the "A" AFW manual isolation valve is stuck Statement open. The operators are directed to disengage the manual handwheel on the "B" AFW flow control valve. Other operators are directed to unisolate the ADVs and T8Vs.

04:41:10 "A" OTSG 1evel decreases below steam shroud. IDADS Print ,

=

out. '

04:42:42 Operator stops the "B" HPI pump. The makeup pump IDADS Print '

l is continuing to run. out l

04:42:56 Operators close the "A" & "B" HPI injection IDADS Print

! valves. out 04:43:50 Operator notes loss of RCP seal injection Operator fl ow. Statement 04:43:54 Operator restarts the "B" HPI pump to re- '

.lDADS Print establish RCP seal injection flow. ,out 04:49: . Leakage (steam) from the damaged makeup Onera t?'

pump is released via the suxiliary buildin, . 4.en.. .c

9 ventilation system. The release is within Technical Specification limits. The 5

auxiliary building stack radiation monitor alarms and isolates the auxiliary building ventilation system, stopping the release.

04:50:19 Operator stops the "B" HPI pump. (Note: IDADS Print Operator had re-aligned valves in the seal out injection flow path.)

04:50:30 Operator again notices loss of seal flow, and Operator restarts the "B" HPI pump. (Note: loss of RCP Statement seal flow is due to the failure of the makeup pump. The operators are not yet aware of the failure.)

04:52 One of the four SR0s on shift (not the shift Operator supervisor) collapses in front of the control Statement panel. This SRO had previously assisted in closing the ADV and TBV manual isolation valves.

05:00 Operator in Control Room hears a loud noise. Operator He looks down at makeup pump ammeter and notes it is reading about 1/3 of normal Statement running current. He realizes the makeup pump has been damaged (due to lack of suction).

05:00:10 Operator trips makeup pump. Operator opens Operator makeup tank discharge valve, which allowed Statement water to spill out of the damaged makeup pump onto the pump room ftoor. The operator subsequently shuts the discharge valve.

Approximately 450 gallons is spilled.

05:05 RCS pressure decreases out of PTS region. A three Operator hour soak is initiated. (RCS Pressure = 870 psig. Statement /

RCS temperature = 428 F).

IDA05 Print out 05:05 An Ambulance is called for SRO who collapsed. Operator 7 Statement 05:09 Both AFW pumps are manually stopped while OTSG

> IDADS Print level is reduced via the OTSG drain lines out to allow re-establishment of normal MFW flow with the condensate pumps.

05:27 Operators isolate the makeup pump. Note: Operators ' Operator isolate the pump by entering the pump room Statement which contains airborne radioactivity and 3 to 4 -

_~~..;__ ~

~ inches of contaminated wat:r o? the ~1oor. The operators do not wear respiratc.s because

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they were not available in the area and thus become contaminated due to water on the floor.)

05:29:04 Operatorsstopthesecond("A")RCP. IDADS Print out 05:33 A smoke detector locks-out Rad Waste Area Operator Exhaust Fans. It is believed that this is Statement caused by damage to the Waste Gas Compressor which was damaged due to water from the flash tank which was filled when the makeup tank overflowed.

05:40 Main Steam Line Failure Logic is " inhibited." Operator This pemits MFW flow to the OTSGs. Statement 05:46:7 Reactor building radiation monitor fails due to shutting the suction valve when SFAS initiated and isolated the reactor building.

05:54 A non-licensed operator loses his security badge. Security He is escorted to the Control Room by a Security Report /

Guard. The Control Room calls security and requests Operator that a spare security badge be brought to the Statements Control Room.

06:06:00 Operators " Bypass" SFAS. Operator Statement 06:11 Momentary " Loss of ICS or Fan Power" alam. Operator

• The $1 and 52 switches remain closed and the Statement alam clears without operator action. No equipment response is noted.

06:14 " Loss of ICS or Fan Power" alam. ICS-controlled Operator valves again receive 50% demand signals. Statement Operators imediately reset switches Si and 52 to restore ICS power. ICS-controlled valved again reveive 100% demand signals. Operators manually shut the valves from the control room.

06:15 Security brings a spare security badge to the Control Security

Room. Report 07

00 SRO released from hospital. Operator Statement 08:41 Teminated Unusual Event. Emergency Coordinator Log a

CPYSTAl. RIVER llNIT 3 - REACTOR TRIP JANilARY 1, 1986 - (B, M0ZAFARI, NRR)

PROBLEM:

A REACTOR TRIP CAllSED BY FLUX-TO-FLOW IMBALANCE SIGNIFICANCE:

POTENTIAL REACTOR COOLANT PilMP/ SEAL FATLURE CIRCUMSTANCES: '

PLANT AT 93% POWER '

REACTOR TRIP WHEN LOW FLOW CREATED FLUX-TO-FLOW IVBALANCE t PRESSURE FLUCTUATIONS IN STEAM GENERATOR CAllSED LnW LEVEL SG SIGNALS THAT INITIATED EFW VIA EFIC (0LD PROBl.EM)

ALARMS INDICATE LOW FLOW TO PCP SEAL (No LEAKAGE INDICATED)

MAKEUP VALVE OPENED TO MAINTAIN PZR LEVEL WHICH DROPPED TO 50" (CLOSED h MINUTES LATEP)

OPERATOR NOTED AMPERAGE DROP IN RCP LOOSE PARTS MONITOR INDICATED HIGH MOTOR VIBRATION OPERATOR SECURED PUMP (BYPON-JACKSON) 2 MINilTES AFTER REACTOR TPTP 6 MINUTES AFTER REACTOR TRIP, ONE MFW PlJMP WAS SHUTDOWN; SECOND PUMP REMAINED ON TO C00LDOWN EFW WAS SHUTDOWN 10 MINtJTES AFTER TRIP MSSV STUCK OPEN ON TRIP; MANUALLY RESEATED (OLD PROBLFM) r FOLLOWUP:

REGION II SENT INCIDENT RESPONSE TEAM ON JANilARY 3, 1985 PUMP TO BE INSPECTED WHEN PLANT REACHES MODE 5 (EXPECTED 1/6/86) TO DETERMINE EXTENT AND CAUSE OF PUMP FAill]RE -

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4 PEACH BOTTOM liNIT ? - REACTOR TRIP AND WATER HAMMER j DECEMBER 26, 1985 - (G, GEARS, NRR) l j PROBLEM: WATER HAMMER, LOW REACTOR WATER LEVEL: OPERATOR ERROR l RESULTED IN SCRAM i

i SIGNIFICANCE:

j WATER HAMMER I OPERATOR ACTION PESilLTED IN SCRAM j DISCUSSION:

] UNIT 2 SCRAMMED FROM 44" POWER DUE TO LOSS OF "A" RFP DN

OVERSPEED TRIP RFP "A" PROVIDING MOST OF THE RE0llIRED FEEDWATEP WITH RFP "B" EXPERIENCING FLOW AND OPERATIONAL DIFFICllLTTES, i

RFP "C" PilT INTO SERVICE ATTEMPT WAS LATER MADE TO PUT "B" BACK INTO SERVICE AND TAKE "C" i OUT OF SERVICE (SWAPPING)

SWAPPING OF "B" AND "C" RESULTED IN RFP CHECK VALVES St.AMMING AND DAMAGE TO 1 INCH DRAIN LINE ON "C" SYSTEM i RCIC WAS STARTED TO CONTROL WATER LEVEL .

LEAKAGE FROM SHEARED DRAIN l.INE WAS CONTROLLED BY ISOLATION OF

! THE CONDENSATE AND FEEDWATER SYSTEMS FROM THE CONTROL ROOM, l NO PERSONNEL CONTAMINATION PEPORTED AND MAlli STACK REl. EASES i WERE NORMAL FOR A SCRAM (0.6% OF-TS LIMIT)

\ FOLLOW-UP:

i REGION I IS FOLLOWING UP ON REPAIR TO DRAIN LINE AND LICENSEE INSPECTION OF CONDENSATE AND FEEDWATER SYSTEMS LICENSEE ISSlJED INSTRUCTIONS TO ALL OPERATORS NOT T0 " SWAP" '

[ RFP PUMPS i

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HATCH UNIT 2 - LOSS OF DIESELS DECEMBER 28, 1985 - (G, GEARS, NRR)

PROBLEM: ALL UNIT 2 DIESELS DECLARED INOPERABLE SIGNIFICANCE: GRID ANOMALIES RESULT IN D/G TRIPPING ON REVERSE CURRENT UNDER HATCH OPERATING PROCEDURES DISCUSSION:

UNIT 2 IN HOT S/D FOR TURBINE INSPECTION "1B" (SWING D/G) BEING RUN FOR NORMAL SR TEST TRIPPED ON REVERSE CURRENT, LICENSEE DECLARED "1B" INOP AND TEST STARTED "2A" AND "2C" l

PER TSs BOTH "2A" AND "2C" ALSO TRIPPED ON REVERSE CURRENT D/G TEST PROCEDURE CALLS FOR COMPARING PHASE 3 TO PHASE 1 PRIOR TO " SYNCHING" D/G TO THE GRID TO PREVENT REVERSE CURRENT TRIPS UNUSUAL GRID CHARACTERISTICS RESULTED IN OTHER PHASES BEING SIGNIFICANTLY HIGHER THAN PHASE 3 AND THEREFORE AS "1B" WAS BEING TAKEN OFF LINE, REVERSE "CURRENTING" OCCURRED RESULTING IN THE TRIP THE SAME PROCEDURES WERE USED IN THE ATTEMPT TO PUT,"2A" AN'D "2C" ON LINE AND THEREFORE REVERSE CURRENT TRIPPING ALSO OCCURRED LICENSEE REQUESTED LOAD DISPATCHER TO LOWER GRID VOLTAGE FROM 517 KV TO 509 KV; PROBLEMS RESOLVED LICENSEE INDICATED THAT D/Gs WOULD HAVE SUCCESSFULLY LUADED ON LOSS OF POWER SINCE 4160 VOLTS BUSES WOULD BE DISCONNECTED FROM THE GRID FOLLOW-UP:

REGION II FOLLOWING LICENSEE'S CORRECTIVE ACTIONS INCLUDING DEVELOPING NEW PROCEDURES TO CHECK ALL THREE PHASES PRIOR T0

~

" SYNCHING" D/G ON LINE DURING SR TESTING l

1

REACTOR SCRAM

SUMMARY

WEEK ENDING 01/05/86 I. PLANT SPECIFIC DATA DATE SITE UNIT POWER RPS CAUSE COMPLI- YTD l

CATIONS TOTAL 12/31/85 POINT BEACH 2 100 A EQUIP / BOP YES -

12/31/85 RIVER BEND 1 25 A EQUIP /TURB YES -

12/31/B5 GRAND GULF 1 98 A PERSONNEL YES -

12/31/95 INDIAN POINT 2 100 A EQUIP /PZR SPRY NO --

01/01/86 RIVER BEND 1 19 A EQUIP /FD HTRS NO 1 01/01/86 PEACH BOTTOM 2 90 A EQUIP /STM SEP NO 1 01/01/86 CRYSTAL RIVER 3 96 A EQUIP /RCP YES 1 01/02/86 DIABLO CANYON 2 95 A EQUIP / BOP YES 1 01/04/86 TMI 1 20 A EQUIP / BOP YES 1 01/04/86 MAINE YANKEE 1 75 M PERSONNEL YES 1 01/05/86 MCGUIRE 1 100 A EQUIP /FD RG VLV NO 1

SUMMARY

OF COMPLICATIONS SITE UNIT COMPLICATIONS POINT BEACH 2 RCPS TRIPPED MSIV FAILED

, RIVER BEND 1 LOST 500KV LINE

_., GRAND GULF 1 HPCS AUTO STRT FAILED CRYSTAL RIVER 3 MSSV STCK OPEN DIABLO CANYON -

2 RCPS TRIP TMI 1 MSSV CLSD MANUALLY -

MAINE YANKEE 1 PRI ACTVTY TRANS ABV TS LIM e

II. COMPARISON OF WEEKLY STATISTICS WITH INDUSTRY AVERAGES SCRAMS FOR WEEK ENDING 01/05/86 SCRAM CAUSE POWER NUMBER NUMBER 1984 OF NORMALIZED (6) WEEKLY SCRAMS (5) TO 1984 AVERAGE (3) (4)

• • POWER 215%

EQUIP. RELATED >15% 9 8.1 3.9 (60%)

PERS. RELATED(7) >15% 3 2.7 1.8 (28%)

OTHER(8) >15% 0 0.0 0.8 (12%)

11 Subtotal **

12 10.8 6.5

• • POWER <15%

EQUIP. RELATED <15% 0 0.0 1.4 (46%)

PERS. RELATED <15% O O.0 1.4 (46%)

OTHER <15% 0 0.0 0.2 (8%)

• • Subtotal **

O O.0 0.0

• • • Total ***

12 10.8 9.5 MANUAL VS AUTO SCRAMS TYFE nut 1BER NUMBER 1984 OF NORMALIZED WEEKLY SCRAMS TO 1984 AVERAGE MANUAL SCRAMS (9) 1 0.9 1.1 AMTOMATIC SCRAMS (9) 11 9.9 8.4 l

' :.'g  : :--; . ~-

I

l NOTES (1) PLANT SPECIFIC DATA BASED ON INITIAL REVIEW 0F 50.72 REPORTS FOR THE WEEK OF INTEREST. PERIOD IS MIDNIGHT SUN. THROUGH MIDNIGHT SUN. SCRAMS ARE DEFINED AS REACTOR PROTECT!YE ACTUATIO WHICH RESULT IN ROD MOTION,. AND EXCLUDE PLANNED TESTS OR SCRAMS AS PART OF PLANNED SHUTDOWN IN ACCORDANCE WITH A PLANT PROCEDURE.

(2) RECOVERY COMPLICATED BY EQUIPMENT FAILURES OR PERSONNEL ERRORS UNRELATED TO CAUSE OF SCRA'i (3) 1984 INFORMATION DERIVED FROM AEOD TRENDS AND PATTERNS REPORT OF UNPLANNED REACTOR TRIPS IN 1984, DATED 9/11/85. (SEE TABLES 2.0-2, 2.1-4, AND 2.2-1) WEEKLY DATA DETERMINED BY TAKING TOTAL

.IRIPS IN A GIVEN CATEGORY AND DIVIDING BY 52 WEEKS / YEAR,

^

(4) IN 1984, THERE WERE A TOTAL OF 492 AUTOMATIC AND MANUAL REACTOR d TRIPS AT 83 REACTORS (HOLDING FULL-POWER LICENSES). THIS YIELDS AN AVERAGE RATE OF 5.9 TRIPS PER REACTOR PER YEAR AND AN A

, RATE OF 9.5 TRIPS PER WEEK FOR ALL REACTORS.

(5) BASED ON 92 REACTORS HOLDING A FULL POWER LICENSE, AS OF 11/30/85.

(6) i NORMALI2ED VALUES ALLOW COMPARISON TO 1984 DATA BY MULTIi ACTUAL 1985 VALUE BY: 183 REACTORS IN 1984)= 0.90 (92 REACTORS IN 1985)

(7) PERSONNEL RELATED PROBLEMS, AS USED IN AE0D TRENDS AND PATTERNS REPORT, INCLUDE HUMAN ERROR, PROCEDURAL DEFICIENCIES, AND MANUAL STEAM GENERATOR LEVEL CONTROL PROBLEMS, (8)

' "0THER" INCLUDES AUTOMATIC SCRAMS ATTRIBUTED TO SOME COM 0F HARDWARE FAILURE AND HUMAN ERROR, ENVIRONMENTAL.CAUSES (LIGHTNING), SYSTEM DESIGN, OR UNKNOWN CAUSE.

l i

(9)

MANUAL SCRAMS ONLY AND AUTOMATIC SCRAMS ONLY ARE DERIVER FROM  ;

TOTAL AUTOMATIC AND MANUAL SCRAMS DATA PROVIDED IN TABLE l?

OF AEOD REPORT.

ENCLOSURE 3 Pa;e No. 1 01/08/26 0FERATINS REACIORS EVENTS MIETINS FOLLOWUP ITEMS AS CF MEE!!h5 86-01 DN JANUARY 6,1926 (IN ASCENDIh3 MEETINS ! ATE, NSSS VENDOR, FACILITY ORDER)

KEETINS FA !LITY RESFCNSIBLE TASK IESCRIPTICN SCHEDULE CLOSED CATE CCRMENTS N'5SER/ NSSS VE C R/ CIV!SICN! COMPLET. BY 20:UMENT, r,EETIh3 EVENT IESCRIF. IN:!VIDUAL DATE(El MEETINS,ETC.

DATE CRYSTAL RIVER 3 E!CS/PARR, D. CCNSIIER NEED FOR ADDITICNAL 12/30/85 CLOSED 01/06/96 EICS CONS 10ERlh5 01/03/25 !W / TEMF. LOSS / REEUIREMENTS CN ALARMS / 09/ 0/25 REVIEW IE!n! 0:CNEE 1 LOSS CF CF hh! 12/25,SA AhN"h:!ATORS 07/30/E5 ACCOMFLISHEt ANNUN:!A.

UN:ER TAC h0 (4/25/251 IN ANAL.

60378 CF REGU!KEP.ENTS.

S5-13 TURKEY PCINT 3 PSB /SAMM:LL, W. REVIEW A:ECUACY OF SCVERh:R 02/22/86 CPEN / /

CE!!3/25 W / F ST-TRIP / IESIGN CN TURBINE IRIVEN AFW 01/05/66 LCSS CF AFW PUMFS 10/13/25 95-14 SE;"0YAH IL /STAHL C INITIATE STAFF PEVIEW 0F TVA 12/30/25 CLOSED 01/06/E6 02/26/25 h /th!IS1&2 / SUSMl!IALS 09/30/85 REVIEW IE!h5 VOLUNTARY / / ACCCMPL1SHED SHUT;C a BY TVA CN ER TAC N2.

BE:A"SE OF EQ 60409 & 60410 INA:EC';A:!ES 23-21 TROJAN PSB /SHAFAKER / REEIAMINE NEED FCR THIS 01/31/E6 0?En //

10/25/25 / Ih: RRECT / INSTALLATION AND SENERIC / /

SETF0!niS FOR APPLICA!!LITY / /

TRIP CF AFW PURFSCNLCW SUCTION FRESSURE 63-23 BR:nS FERRY IE /F KANTCR CISCUSS WITH FEMA NR FOSITION 01/30/86 0 FEN // TO BE DISCUSSED

!!/12/85 / OFFSITE / WITH RESARD TO EMERSEN:Y PLAN 12/10/95 DURINS NEIT CCNTAMIN. .

EIERCISE / /

. FEMA /hRC STEERINS INCIDENT CURIh5 CCMMITTEE MONTHLY E"IRSEN:YPLAN MEETING EIEFCISE 1

4 23-26 RANCH 3 !!CD DHFS/ RUSSELL R

' WILL REVIEW WITH H R DENICN THE 12/31/95 CLOSED 01/06/96 12/09/25 / REACTOR TRIP / EXISTINS POLICY ON INFORMATION / / JANUARY 03, PLACED IN LICENSED OFERATCR / / 1956 MER R.

FILE RUSSELL TO H.

DENTON E5-26 RANCHO SECD RSE /LANTI E LETERMINE THE NEED FOR 01/30/E6 CLOSED 01/05/26 l 12/09/85 / REA:TCR TRIP / OFERATION CF THE HISH FRESSURE // JANUARY B, 1996 INJECTION SYSTEM DURING THE / / MEMO C. THCMAS CEC. 5,1925 CVERHEATINS EVENT TO 6. HDLAHAN ge... ,,n l

l &N ,

l E3-29 PALD VERIE 1 NRR /CRUTCHFIELD ASSESSMENT CF STARTUF AND OP. 01/30/E6 0FEh i /

l 12/23/E5 'CE / ESFAS / l EIFERIENCE FOR FALO VERIE UNITS / / l l ACTUATION,REACTO 1&2. / /  ;

l R TRIP, AND i C0"FDNENT MALFUNCTIONS

s

• i Page No. 2

01/02/E6 OPERATING REACTCRS EVENTS MEETING FDLLOWUP ITEMS AS OF MEETINS 86-01 DN JANUARY 6,1996 i

, (IN ASCENDINS REETINS DATE, NSSS VENDOR, FACILITY CRDER) i GEETING FACILITY RESPCNS!PLE TASK CESCRIPT!DN SCFEDULE CLOSED DATE COMMENTS

! NUM3ER/ NSSS VEN00R/ DIVISION / CL"FLET. IV DOCUMENT, l'

GEETINS EVENT CESCRIP. INDIVIDUAL DATE(S) MEET!n6,ETC.

8 ATE i .. -

l 85-29 MULTI NRR /HOLAHAN, 6

SUMMARY

FCR CALENDAR YEAR 1985 01/15/86 CPEN / /

12/23/ES NA / FALO VE8:E / CF 0.R. EVENTS' BRIEFINSS / /

{ STARTUP PRESENTATICNS ON A FER- FLANT / /

l ElFFICULTIES BASIS 3

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