ML20154N447
| ML20154N447 | |
| Person / Time | |
|---|---|
| Site: | Palisades, Perry, Surry, South Texas, 05000000 |
| Issue date: | 09/07/1988 |
| From: | Jaudon J Office of Nuclear Reactor Regulation |
| To: | Rossi C Office of Nuclear Reactor Regulation |
| References | |
| OREM-88-036, OREM-88-36, NUDOCS 8809290309 | |
| Download: ML20154N447 (22) | |
Text
. _ _ _ _ _ _ _ _ - _ _ _ _ - _ _
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(
i kEMddAN00M FOR: Charles E. Rossi. Director J
Division of Operational Events Assessment l
l Office of huclear Reactor Regulation
]
FROM:
Johns P. Jaudon. Acting Branch Chief Events Assessment Branch j
Division of Operational Events Assessment i
1 Office of Nuclear Reactor Regulation j
1 L
J
SUBJECT:
THE CPERATING REACTORS EVENTS MfETING i
i September 6.1988 MEETING 88 36 i
}
l On September 6, 1988, an Operating Reactors Events meeting (88 36) was held to i
brief senior managers from ARD. OSP AE00. Commission Staff. and Regional
(
Offices on events which occurred since our last meeting on August 30, 1988.
The list of attendees is included as Enclosure 1.
J L
j The events discussed and the 'ignificant elements of these events are presented l
1 in Enclosure 2. presents one event suggested for long term followup and a sumary of reactor scrams for the week ending September 4.1988.
Two i
significant events were identified for input to NRC's Perforrance Indicator L
P rog ram.
f f
i I
Johns P. Jaudon. Acting Branch Chief Events Assessment Branch j
Division of Operational Events Assessnent i
j Office of Nuclear Peactor Regulation l
4 f
i Enclosures-1 As stated cc w/Encio.:
l See Next Page i
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- 8. Davis, elli G. Otek. 130 18 J. N. Grace. 811 J. Calvo. 130 18 R. D. Martin. Elv
- 1. Wambach. 13H 15 J. 8. Martin. DV M. Virgilio. 13E 15 W. Kane. 91 T. Colburn, 13E 21 L. Reyes. Gli K. Perkins 13E 21 E. Greenman. Sill J. Callan. Bly
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- 5. Varga. 14E 4
- 0. Crutchfield. 13A 2
- 8. Scger 14A 2 G. Holahan. 13H 4 G. Lainas 14H 3 L. Shao. 8E 2 J. Partlow. 70 24
- 8. Grires. 9A 2 F. Congel, 10E 4 E. Weiss. AE00 l
T. Martin 12G 18 J. Gutte. ann. SECY A. Thadant. 7E 4 S. Rubin. AE00 R. Barrett. 10E 2 M. Harper. MhBB 4210
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NUCLEAR REGULATORY COMMISSION ej wAs M GTON,0.C. M M n\\,...../
gEPC1 W PfMODAN00M FOR: Charles E. Rossi. Director Division of Operational Events Assessment Of fice of Nuclear Reactor Regulation FRCM:
Johns P. Jauden. Acting Branch Chief Events Assessment Branch Division of Operational Events Assessment Of fice of Nucler,r Reactor Regulation 50 EJECT:
THE OrttAflhG REaCTCDs EVENTS VEETING Septemter 6. 1988 PEEfthG 88 36 On Septerter 6.1988, an Operating Seactors Events meeting (88 36) was held to brief senior managers f rom NRR. 050. Af 00. Comission Staf f. and Regional Offices on events which occurred since eur last meeting on August 30, 1988.
The list of attendees is included as fnclosure 1.
The events discussed and the signiiicant eierents of these events are presented in Enclosure 2. presents one event suggested for long term followup and a sumary of reactor scrams for the week ending September 4.1988 Two significant events were identified for input to hRC's Performance Indicator Program.
W Jo ns P. Ja don. Act'ng Branch Chief Events Asse $ ment Branch Division of Operationai Events Assessment Office of huclear Reactor Regulation
Enclosures:
As stated cc w/ Enc 10.:
See Next Page
F ENCLOSUGE 1 l
l LIST OF ATTEN0EES l
OPEGAT!NG PEACTORS EVENf5 BRIEFING (88 36J September 6. 1988 NAPE ORGAN!?ATIOh NAME ORGAN!!ATIGA
- 0. Crutchfield hAR/00EA P. Baranowsky hAR/COEA S. Yarga NRA/0RP B. Boger NRA/AOR 1 G. Lainas NRA/A08 2 J. Jaudon NRR/00EA C. Schulten NRR/00EA J. Guttmann SECY
- 8. Clayton DEC90 M. L. Rearcon NRR/00EA A. DeAgazio NRR/ORSP R. Gilbert NRR/ORSP C. 8 tel NRA/0RP M. Virgilio NOR/00$P 4
M. Chiramal AECO S. Juergens SECY E. Rossi NRR/00EA L. Rubenstein NER/p0ShP W. Minners RES/ORPS T. Murley 0:hpR R. Auluck OSP/TVA J. Carter h0R/00EA W. LeFave NRR/SPLB J. Wermiel NRP/$PLS G. M. Holahan NRR/ORSP E. B. Temlinson hop /PO4 1
T. Quay NRA/P03 1 K. Eccleston NRR/0RD1 2
- 8. Grimes heR/CRis T. Silho AE00 l
l T. Colburn NRR/P03 3 W. LeFave NRR/SPl0
ENCLOSURE 2 0_PEBATING RE ACTORS EVLNTS.BRJ1[1N(i_$$-JJ EVENTLAllf! SPENT _DRLNy LOCATION:
12-B-1LE,H_ LIE FL INT ll150AY. S[PILMEER 6, 1988, 11;00 A.L SURRY UNIT I FAILURE OF REFUEllNG CAVITY FLOOR SEAL SOUTH TEXAS UNIT 2 (UNLICENSED) CCCPER-BESSEMER O!ESEL FAILED PALISA0ES FUEL BUNDLE STUCK TO BOTTOM 0F UPPER Gul0E STRUCTURE DURING RENOVAL PERRY UNIT 1 FIRE IN CHARC0AL ADSORBERS
88-30 0
SljRRy_UN1T 1 EAILURE OF REFUEllNG C.AVIIY FLOOR SEAL MAY 17, 1988 PROBLEM o
REFUEllNG CAVITY FLOOR !EAL FAILURE 1.0SS OF INSTRUMENT AIR PRESSURE TO THE INFLATABLE SFAL FAILURE OF THE NITROGEN BACKUP SYSTEM TO lNITIATE PASSIVE "J" SEAL FAILED o
EVENT WAS NOT REPORTED TO THE NRC UNTIL SEPTEPBER 1, 1988 AND THE LICENSEE WAS RELUCTANT TO PROVIDE INFORMATION WHEN ASKED, o
IMPROPER OPERATOR ACTION IN RESTORING LEVEL COULD HAVE SIGNIFICANTLY REDUCED ThE SPENT FUEL P00L RESULTING IN HIGH RADIAT10N IN THAT AREA.
l SAFETY SIGNIFICANC{
0 POTENTIAL FOR UNCOVERING A SUSFENDED SPENT FUEL ASSEMELY WITH SUBSECUSENT CLADDING DAMAGE ANO RADIATION HAZARDS, O
POTENTIAL FOR LOSS OF LEVEL IN THE SPENT FUEL POOL, 0.1$GS$10N o
UNIT 1 DEFUELED, o
APPR0X 30.000 G% OF BORATED WATER INTO THE INCORE ROOM.
O INCREASED RADIATICN LEVEL FORCED EVACUAil0N OF W PERSONNEL
'c l
ON MANIPULATOR CRANE.
o USAR INCOPRECTLY STATED THAT THE "J" SEAL WOULD PREVENT EXCESSIVE
- LEAKAGE, l
0 IE IN 84-93. NRC IE BULLETIN 84-03, AND INP0 SOER 35-01 HAD BEEN ISSUED TO ALERT LICENSEES TO THE FOSSIBillTY OF SEAL PROBLEMS.
o AT THIS TIME THE Lif.ENSEES PROCEDURES FOR MANY ASPECTS OF THIS EVENT ARE NOT ADEQUATE.
o CAVITY LEVEL COU W HAVE BEEN MAINTAINED BY USE OF THE LPSI OR RHP l
PbMPS, BUf THE PUMPS WERE OUT-0F-SERVICE BECAUSE NO FUEL WAS IN THE VESSEL.
CONTACT:
R. KARSCH
REFERENCES:
PNO-Ril-88-52, 50.72 # 13347, PORNING REPORTS 09/01/88 AND 09/02/88
SURRY U(ili 1 88-36 O
SURRY 2 IS ALSO SUSCEPTABLE TO THIS TYPE OF SEAL FAILURE AND WILL ENTER REFUELING SOON, o
EVENT TERMINATED BY OPERATOR ADJUSTING THE NITROGEN CEGULATOR ANC OPENING A SHUT LOCAL INSTRUMENT AIR ISOLATICN VALVE TO THE SEAL, o
WATER LEVEL IN THE PEFUELING CAVITY WAS RESTORED BY IMPROPERLY OPENING THE FUEL TRANSFER CANAL GATE VALVE, o
MANUFACTURER (PRESRAY) SAYS THAT THE SURRY SEAL ARRANGFFENT
("J" SEAL hlTHOUT A BACKING PLATE) IS UNIQUE,
[SRRECll.VE_ACTIQN o
DETAllE0 DESIGN REVIEW 0F THE ARRANGEMENT WAS PERFORPED (LACK OF POSITIVE BACKING PLATE ON "J" SEAL, INFLATABLE SEAL SHOULD BE STRONGER MORE RESillANT, AND hAVE MORE CONTACT SURFACE AREA).
EDLLOhuf c
AN AIT HAS PEEN DISPATCHED TO THE SITE.
o CONSIDERING ISSUANCE OF ANOTHER INFORMATION NOTICE,
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88-36 SOUTH TEXAS UNIT 2 j
(UNLICENSED) C00PFR-RES$ EF1 0_lEREL FAllE0 JULY 1988 ER0gtEM JACKET WATER FOUND IN COMBUSTION CHAFBERS WHICH LEAD TO THE DISCOVERY l
GF CRACKED HEADS ON EACH OF THE DIESEL's 20 CYLINDERS, l
l ChUSE l
THE PROBLEM WAS DETERMINE 0 TO BE CAUSED BY IMPROPER INSTAL.lATION OF THE TIMING CHAIN, l
SAFETY SIGMELGAEE
[
MAINTENANCE ACTIVITIES HAY EFFECT DIESEL GENERATOR OPERABil.lTY SUCH THAT THE PROBLEMS ARE NOT DETECTABLE DURING POST MAINTENANCE TEST SURVEllt. ANCES,
f DISCUSSION o
SOME TIME BEFORE JULY 5, 1988 THE LICENSEE REPAIRED THE UNIT-2 "C" j
DIESEL GENERATOR I.UBE Olt LINE TO THE TWO TIMING CHAIN TIGHTENERS, o
THE CHAIN WAS REINSTAI. LED AND TENSION 10 THE CHAIN WAS APPLIED I
USING ONl.Y ONE OF THE TWO TIGHTENERS, o
THIS PROCEDURE ADVANCED THE TIMING CHAIN ABOUT 20 DEGREES, i
o THE TIMING ADVANCE PROBLEM CAUSED THE FUEL TO BE INJECTED AND CONSEQUENTLY COMBUSTED BEFORE THE PISTON REACHED TCP DEAD CENTEP f
(TDC),
j o
PRESSURE STRESSES AND THERMAL STRESSES ON THE DIESEL WERE SEVERE j
AND RESULTED IN MECHANICAL FAILURES WHICH WERE NOT READILY DETECTABLE, o
UNDER HIGH PRESSURE AND TEPPERATURES THE POTENTIAL EXISTED FOR THE PISTON PIN LUBE Olt~ FILM TO DEGRADE AND RESULT IN EXCESSIVE WEAR ON
[
THE BEARINGS, o
IN THE CASE OF SOUTH TEXAS:
ERROS10N AN0/0R CRACKING 0F VALVE RECESS AREAS OCCURRED AT THE f
TOP 0F THE PISTON PROBABLY DUE TO EXCESSIVE HEAT, j
i CONTACT:
C, SCHULTEN REFERENCE i
SOUTH TEXAS UNIT 2 88-36 lHE HEADS CRACKEO, PROBABLY DUE TO THERMAL STRESSES, THIS ENABLED l
JACKET WATER TO ENTER INTO THE CYLINDER AND ERODE THE PISTON, o
THE DIESEL DIO NOT Fall, IT TESTED SATISFACTORILY AND WAS RUN FOR ABOUT 20 HOURS BEFORE A ROUTINE MAINTENANCE PROCEDURE IDENTIFIED JACKET WATER IN THE CYLINDERS.
FOL LOWJJP o
PD-IV HAS PERFORMED AN ONSITE INSPECTION Oc THE O!ESEl$ IN CONJUNCTION WITH REGION l'I.
o PD-IV RECOMPENDS A FLUSH OF THE DIESEL LUBE CIL SYSTEM TO REPOVE IRON UX10E CONTAMINANTS IDENTIFIED DURING ITS lNSPECTION BUT WHICH IS APPARENTLY UNRELATED TO THE TihlNG CHA!N PROB; EMS WITH THE DIESEL.
o PD-IV IS PLANNING TO REVIEW VENDOR MAINTENANCE PRbCEDURES, o
EAB RECOMPENDS THE VENDOR BRANCH BE INFORMED OF PD-IV ACTIVITIES, i
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SOUTH TEXAS UNIT 2 SECT 10N 13 AtlX!LIARY DR!YE. CAE9tATT AND DA!YI riksft and Covernor Dnve tatsers mounted in the camshaf t housing.
~ A split type drive sprocket (12. Tig.13 Labricatics of the sprocket beartags a:c me
- 1) is mounted and keyed on the aft and of the c'tata is from the enga:e tube oil s,s stem, crankshaft. Two camshaft dnve sprockets (6), mounted on a shaft with the camshaft drive Sosed Recalattar Covernor and Oversteed gear (5) are dnven by the mata drive chata Goversor Dnves (3). The dnve gear acuated with the sprocket The drives for the governors are off the drivea the gears (1) mounted on the ends of the ends e( et sprockets and drive gear shafts camshaf ts (2). Two adjustable chata tightener Tig.13 2. A splined male sad as the gmr.
(11) and sprocket assembtles (9) are mausted mer driven shaft mates with a female and as one on each side of the contarframe, so tat to sprocket and gear shaft. A bevel gear em chata teastos can be adjusted. The shaf t (10 the oppostte end of the governor driven shaft Tig.13 2) carrytag the sprocket and dnve usates with a bevel gear se the governor drtve gear rotates ta two bearings *ttich have re.
abaft tirslag the governor.
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Fin and learings 3.
Chata 7.
Overspeed Cov. Drive 11.
Chain fightener 4.
Cae Mousing 8.
Mann Cov. Ortve 12.
Spracket c. Crar.ashaf t Casshaf t and Covernor Ortve Chain
88-36 P.A.liSA0s.S FUEL BUNOLE STUCK TO EQTTOM OF l
EPfL@lQg STRUCTURE _ DURING REMOVA(
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SEPTEMBER 3, 1988 l
E3@ led OURING REMOVAL OF THE REACTOR VESSEL UPPER GUIDE STRUCTURE (UGS) IN
[
PREPARAT10N FOR PLANT REFUELING, ONE FUEL BUNDLE WAS FOUND TO BE STUCK l
TO, AND HANGING FROM, THE BOTTOM OF THE UGS (BOTTOM OF BUNDLE WAS j
19 lNCHES ABOVE THE CORE).
(MSL j
UNKNOWN: STILL UNDER INVESilGATION.
SAF[TY SIGNIFICANCE DROPPED FUEL BUNDLE ONTO CORE COULD RESULT IN DAMAGE TO FUEL CLADDING.
NO REACilvlTY CONCERN DUE TO HEAVILY BORATED CONDjil0NS 00 RING REFUEllNG.
A OROPPED FUEL BUNDLE IS A FSAR CHAPTER 15 ANALYZED EVENT l
IN ACCORDANCE WITH THE STANDARD REVIEW PLAN (NUREG-0800).
DISCUSS 10N f
o ON SEPTEMBER 3, 1988 WHILE IN MODE 6 (REFUELING), A FUEL BUNDLE f
WAS DISCOVERED HANGING FROM THE BOTTOM 0F THE UFPER GUIDE STRUCTURE l
DURING REMOVAL OF THE STRUCTURE.
NO APPARENT FUEL DAMAGE AREA l
RADIATION MONITOR READINGS BELOW Al. ARM SETPOINTS.
j o
CONTAINMENT ACCESS PENETRATIONS AND 1.lNES IN DIRECT CONTACT WITH THE CONTAINF.ENT ATMOSPHERE WERE MANUALLY ISOLATED AS A PRECAUTIONARY MEASURE, NON ESSENTIAL PERSONNEL WERE EVACutTED f
FROM CONTAINMENT, o
WIRES WERE Pl. ACED SEVERAL INCHES FROM SIDES OF BUNDLE (NOT TOUCHING) FIVE FEET BELOW TOP OF BUNDLE TO PREVENT BUNDLE FROM FALLING OVER IN CASE IT DISLCDGED FROM UGS.
o LICENSEE PREPARED PROCEDURE FOR FREEING BUNDLE FROM UGS WITH i
WORKER IN BASKET SUPPORTED BY JIB CRANE USING SPECIAL T001.S.
l.lCENSEE FABRICATED TOOLS AND PERFORMED MOCKUP TRAINING.
CONTACT:
R. KENDALL AND J. THCFPSON
REFERENCE:
50.72 #s 13367, 13374, AND 13384
palls 6 DES 88-36 o
USING PROCEDURE, LICENSEE SUCCESSFULLY GAINED CONTROL OF STUCK FUEL DUNDLE, FREED BUNDLE FROM UGS, AND LGhERED BUNDLE ONTO ADJACENT FUEL ASSEMBLY AND SECURED BUNDLE BY i.EANING IT AGAINST THE SIDE OF THE CORE BARREL.
SIMILAR_EygNIS o
ON april 23, 1988 AT WATERFORD 3 A CONTROL ELEMENT ASSEMBLY WAS FOUND 10 BE STILL LATCHE0 TO THE BOTTOM OF THE UGS DURING REMOVAL OF THE UGS FROM THE REACTOR VESSEL FOR REFUELING.
o EVENTS SIMILAR TO WATERFORD HAVE OCCURRED AT ANO-1 AND CRYSTAL.
- RIVER, I
EOL10hkP REGION Ill HAS SENT ADDITIONAL INSPECTORS TO THE SITE AND IS CONTINUING TO FOLLOWUP.
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88-36 PERRY UNIT 1 FIRE IN CHARCOAL AD,,$QHEM SEPTEMBER 3, 1988
!LROB.LfM FIRE IN OFF GAS SYSTEM, CBE
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UNKNOWN IGNITION OF fly 0ROGEN, SAFETY SIGNIFICANCE UNAVAILABillTY OF COMPLETE OFF GAS 1REATMENT SYSTEM.
DISCUS $1QN o
OPERATING AT 70% POWER, o
HAD INDICATED LOSS OF AIR EJECTOR.
o STARTED SECOND EJECTOR WITHIN 5 MINUTL5, o
HYOROGEN CONCENTRATION INCREASED TO GREATER THAN 5%,
l o
OBSERVED ELEVATED TEMPERATURE IN FIRST BEDS, o
BYPASSE0 FIRST BEDS AND ESTABLISHED NITROGEN PLIRGE, l
o NORMAL FLOW MAINTAINED THROUGH REMAINING 3 BEOS PER !RAtN, o
RADIATION LEVEL INCREASED FROM ABOUT 100 TO AB001 1.000 CPM 00E TO PURGE, EQll0WUP o
LICENSEE TO MAINTAIN NITROGEN PURGE FOR ABOUT 2 WEEKS, o
LICENSEE INVESilGATING CAUSE OF HYOROGEN IGNITION, o
RESIDENT INSPECTOR TO MONITOR LICENSEE ACTIVITIES, CONTACT:
J. CARTER
REFERENCES:
50.72 #s 13377, 13379, 13383, AND 13386.
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,Page No3 M/02/BO-PERFORMMCE INDICATORS $1ENIFICMT EVENTS PLCT NME EVENT EYtui N SCRIPi!0N GTR$16MIFICANCE DATE
$URRY1 05/17/II FAILORE OF BAcrVP REFUELIN6 CAViff SEAL RESULTED IN LOSS 0 POTENTIAL FOR OR ACTUAL DE6RADA110N OF 15,000 6ALLONS OF RE!.CTOR 6RADE BORATED NATER MO 0FFUELINTEGRITY DRAlhDOWN OF REFUEL!lii CAVITY.
PALISALES 09/03/i9 FUEL IL GLE IkADVERTENT;Y FEMOVID FFOM CORE DURING 0 FOTENTIAL FOR OR ACTUAL CEiFAtai!ON 9EMOVAL OF UFFER 6ditt STRUCTURE.
OF FUEL INTEGR!TY k
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i REACTCR SCRM SLY, PAR $
WEE (ENDING 09/04/09 l
!. PLANT SFECIFIC DATA DATE SITE UNIT F0eER 513hAL CAUSE COMPLl-YTD VfD VfD CAi!0h5 AB0VE BELOW TOTAL 151 151 09/31/93 SALEM 1
100 A EQUIPPENT NO 2
1 3
01s31/93 SALEM 2
71 A EGulFMENT N0 5
1 6
09:01/89 DIARO CAMC4 2 100 A EQUIPMENT N0 3
0 3
05/01/89 DIABLOCA4fCN 1
13 A EGUIPFENT N0 3
2 5
09/02/i8 CALLA 4f 1 100 A PER$0nEL N0 5
1 6
09/04/84 ERAIDn500 2
60 M EDUlPMENT YES 6
3 9
09/04/B9 HATCH 1 100 A EQUIPPENT N0 4
0 4
SliE UNIT COMPLICATIONS l AIDE 000 2 PEACTCR PANUALLY TR!FFED AS STR $!N LW AFFROAChiD LCd LYL TR!P St. PT. LEvil t
CECLINED dal DLE TO INC8 EASE IN STEAM FLOW, CAUSE UNt%0s4,iR0rEN t!hE TO HESiWE l
TMNSMlffER FROM C040ENSATE DISC 4:SE ALONG WITH CLO66ED CCNL%Si SCFEENS Hl tvt C0%t0L i
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COMFARISON OF WEE):L/ STATISTICS WITH INDUSTRY AVERAGES SCRAMS FOR WEEK ENDING 09/04/80 SCRAM CAUSE POWER NU:1BER 1980 1987 1986 1985 OF
.EEKLY WEEKLY WEEKLY WEEKLY SCRAMS (S)
AVE? AGE AVERAGE AVERAGE AVERAGE YTD (3)(4)
(8)(9) t POWER > 15'/.
EQUIP. RELATED
' 1 S */.
5 0.3 3.9 4.0 S.4 PERS. RELATED(6) > 1 S'/.
1 1.0 1.3 1.9 2.v OTHERt7)
'15%
0 0.7 1.2 0.4 0.6
- Subtotal **
6 S.0 6.4 6.5 9.0 t*
FOWER < 1 S *'.
EOUIP. RELATED
< 1 S'/.
1 0.6 1.2 1.4 1.3 PERS. RELATED
<15%
0 0.4 0.6 0.8 0.9 OTHER
<1S%
0 0.2 0.3 0.0 0.2
- 6 Subtotal 64 1
1.2 2.1 2.4 2.4 att Total ***
7 6.2 8.S 8.9 10.4 MANUAL VS AUTO SCRAME TYPE NUMBER 1988 1987 1986 1985 OF WEEKL'r WEEFLY WEEKLY WEEKLY SCRAMS AVERAGE AVERAGE AVERAGE AVERAGE YTD MANUAL SCRAMS 1
1.0 1.4 1.0 1.0 nUTOMATIC SCRAMS 6
S.7 7.0 7.9 C.4 e
4 NOTES 1.
PLANT SPECIFIC DATA BASED ON INITIAL REVIEW OF 50.72 REPORTS FOR THE WEEK OF INTEREST. PERIOD 15 MIDNIGHT SUNDAY THROUGH MIDN!GHT SUNDAY. SCRAMS ARE DEFINED AS REACTOR PROTECTIVE ACTUATIONS WHICH RESULT IN R00 MOTION, AND EXCLUDE PLANNED TESTS OR SCRAMS AS PART OF PLANNED SHUTDOWN IN ACCORDAhCE WITH A PLANT PROCEDURE. THERE ARE 109 REACTORS HOLDING AN OPERATlhG LICENSE.
2.
COMPLICATIONS: RECOVERY COMPLICATED BY EQUIPNENT FAILURES OR PERSONNEL ERRORS UNRELATED TO CAUSE OF SCRAM.
3.
PERSONNEL RELATED PROBLEMS INCLUDE HUMAN ERROR. FROCEDURAL DEFICIENCIES.
AND MANUAL STEAM GENERATOR LEVEL CONTROL PROBLEMS.
4.
"0THER" lhCLUDES AUTOMATIC SCRAMS ATTRIBUTED TO ENVIRONMENTAL CAUSES (LIGHTNING). SYSTEM DESIGN. OR UNKNOWN CAUSE.
A J
e
.