ML20245D841
| ML20245D841 | |
| Person / Time | |
|---|---|
| Site: | Harris, Grand Gulf, Byron, Surry, Robinson, 05000000 |
| Issue date: | 09/28/1988 |
| From: | Jaudon J Office of Nuclear Reactor Regulation |
| To: | Rossi C Office of Nuclear Reactor Regulation |
| References | |
| OREM-88-038, OREM-88-38, OREM-YY-XXX, NUDOCS 8810070234 | |
| Download: ML20245D841 (22) | |
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&S MEMORANDUM FOR:
Charles E. Rossi, Director Division of Operational Events Assessment FROM: Johns P. Jaudon, Acting Chief Events Assessment Branch Division of Operational Events Assessment SU9 JECT: THE OPERATING REACTORS EVENTS MEETING SEPTEMBER 27, 1988 MEETING 88-38 On September 27, 1988, an, Operating Reactors Events meeting (88 38) was held to- h brief senior managers from NRR, OSP, AE00, RES, Commission Staff, and Regional (
Offices on events which occurred since our last meeting on September 20, 1988. (
j The list of-attendees is included as Enclosure 1.
l
..' j The events discussed and the significant elements of these events are presented in Enclosure 2. Enclosure 3 presents a summary of reactor scrams. Four 'l significant events were identified for input to NRC's performance indicator program. One event was suggested for long-term followup.
h 'I'rY QD 'y t(OC rD - 4 91/ Johns P. Jaudon, Acting Chief N'M Events Assessment Branch 9 '4/ V Division of Operational Events Assessment
Enclosures:
As stated cc w/ Encl.:
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J. Taylor,17G-13 R. Lo, 148-20 E. Beckjord, NL-007 L. Kintner J14B-20 W. Russell. R1 C. Patel, 14H-22 J. N.-Grace, Rll H. Berkow, 14H-22 B. Davis, R!l!
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J. Partlow, 70-24 B. Grimes, 9A-2 F. Congel. 10E-4 E. Weiss, AE00 T. Martin, E00 J. Guttmann, SECY A. Thadani, 7E-4 S. Rubin, AE00 J. Forsyth, INPO R. Barrett 10E-2 M. Harper, MNBB 4210 W. Lanning, MhBB 3302 l
____._____m._ _ _ _ . _ _ _ . _ . _ _ _ _ _ _ _ _ _ _ . - _ _ _ _ _ . _ _ _ _ _ _ . _ _ . _ _ _ _ . _ _ . _ _ . . _ _ _ . _ _
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SEPna ng MEMORANDUM FOR:
Charles E. Rossi, Director Division of Operational Events Assessment FROM: Johns P. Jaudon, Acting Chief Events Assessment Branch Division of Operational Events Assessment
SUBJECT:
THE OPERATING REACTORS EVENTS MEETING September 27, 1988- MEETING 88-38 On September 27, 1988, an Operating Reactors Events meeting (88-38) was held to brief senior managers from NRR, OSP, AE00, RES, Conunission Staf f, and Regional Of fices on events which occurred since our last meeting on September 20, 1988.
The list of attendees is included as Enclosure 1.
The events discussed and the significant elements of these events are presented in Enclosure 2. Enclosure 3 presents a sursary of reactor scrams. Four l
significant events were identified for input to NRC's performance indicator program. One event was suggested for long-term followup.
f e , m
/Johs'.Jud . Acting h ief L Events Ass s nt Branch Division of Operational Events Assessment
Enclosures:
As stated cc w/ Encl.:
See hext Page l
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ENCLOSURE 1 l
LIST OF ATTENDEES OPERATING REACTORS EVENTS BRIEFING (88-38)
September 27, 1988 ORGANIZATION NAME ORGANIZATION NAME C.E. Rossi NRR/00EA- S. Varga NRR/DRP J. Zwolinski NRR/DLPQ W. Minners RES/DRPS E. Adensam NRR/DRP L.L. Kintner NRR/P02-1
- v. Benaroya AEOD/DSP R. Auluck OSP B. Buckley NRR/DRPR W. Troskoski EDO D. Fischer NRR/DOEA A. Vietti-Cook OCM/LZ D.R. Muller NRR/PDill-2 L. Olshan NRR/PDl!!-2 J.W. Thompson NRR/DOEA T.B. Silko AE00 P.L. Eng NRR/00EA W. Lyon NRR/SXRB P. Baranowsky NRR/00EA C. Schulten NRR/00EA l
i
/
OPERATING REACTORS EVENTS BRIEFING 88-38 EVENTS ASSESSMENT BRANCH LOCATION: _12-B-ll WHITE FLINT TUESDAY, SEPTEMBER 27, 1988, 11:00 A.M.
I HARRIS LOSS OF RHR DUE 10 MAINTENANCE ERROR BYRON UNIT 1 IMPROPERLY MONITORED REACTOR VESSEL INVENTORY LOSS DURiNG REFUEllNG HARRIS AND ROBINSON ENVIRONMENTAL QUALIFICATION .
PROBLEMS OF TARGET ROCK VALVES l
TDI INTERCOOLER ADAPfER FAILURE
' GRAND GULF 1 ON DIESEL
-SURRY 2 1HINNING 0F MAIN FEE 0 WATER PIPING
88-38 HARRIS UNIT 1 LOSS.0F_RHR DUE TO MAINTENANCE ERROR SEPTEMBER 21, 1988
!LR0lLLM SUDDEN LOSS OF RHR WHEN THE "A" RHR PUMP LOST POWER DUE TO A MAINTENANCE ERROR, THE *A" EDG WAS OUT-0F-SERVICE AND THE
- B" TRAIN OF RHR WAS OPERABLE, CAUSE THE "A" TRAIN ELECTRICAL DISTRIBUTION WAS INADVERTENTLY DEENERGl2ED (LOST ST ARTUP TRANSFORMER "A") DURING RELAY CREW MAINTENANCE SIGNIFICANCE LOSS OF BOTH TRAINS OF RHR (THE "A" TRAIN EMERGENCY POWER SUPPLY WAS ;
l TAGGED OUT) FOR APPR0XIMATELY ONE HOUR COULD HAVE RESULTED IN BOILING lN THE VESSEL IF ALTERNATE HEAT REMOVAL WERE NOT AVAILABLE.
DISCUSSION o RHR TRAIN "A" WAS LOST DUE TO THE ELECTRICAL DISTRIBUTION FOR' TRAIN "A" INADVERTENTLY DEENERGl2ED o RHR TRAIN "B" START TOOK 12 MIN TO BRING UP TO ONLINE TEMPERATURE (NORMAL) o THE "A" EDG WAS TAGGED OUT-0F-SERVICE o Rx VESSEL HEATUP WAS 10' F FROM (96* TO 106*F) o THE LICENSEE HAD PERFORMED D/G MAINTENANCE ON BOTH DIESELS WHILE IN MODE 5 ( WITH LOOP NOT FILLED) TRAIN "B" EDG ON 9/20; TRAIN "A" EDG ON 9/21 FOLLOWUP o THE FORTHCOMING GL ON LOSS OF RHR PROBABLY WOULD NOT HAVE PREVENTED THIS EVENT FROM OCCURRING o THE R1, REGION, AND EAB ARE FOLLOWING THIS EVENT TO UNDERSTAND T/S COMPLl ANCE FOR COLD SHUTDOWN WITH LOOPS NOT FILLED o POSSIBLE GENERIC MISUNDERSTANDING 0F T/S OPERABILITY STATEMENT WITH REGARD TO SAFETY-RELATED EQUIPMENT WITH A LOSS OF THE EMERGENCY POWER SUPPLY CONTACT: J. THOMPSON (301) 492-1175
REFERENCE:
50,72 #13505 l I
88-38 BYRON UNIT 1 IMPROPERLY MONITORED REACTOR VESSEL INVENTORY LOSS DURING REFUEllNG SEPTEMBER 19, 1988 PROBLEM LOSS OF SHUTDOWN COOLING TO UNIT 1 FOR APPR0XIMATELY 15 MINUTES, CAUSE OPERATORS COMMENCED VESSEL DRAIN DOWN ACTIVITIES WITHOUT QUANTITATIVE REACTOR VESSEL WATER LEVEL INSTRUMENT ATION, VISUAL INDICATION OF VESSEL LEVEL WAS NOT INDICATIVE OF ACTUAL LEVELS. ,
SAFETY SIGNIFICANCE UNMONITORED REACTOR VESSEL DRAIN DOWN CAN RESULT IN CAVITATION OF RHR PUMPS THEREBY REMOVING CORE DECAY HEAT REMOVAL CAPABILITY, DISCUSSION o 1A RHR PUMP PROVIDING SHUTDOWN COOLING AT APPROX 3000 GPM.
l O LICENSEE COMMENCED CAVITY DRAIN DOWN USING THE IB RHR PUMP TO PERFORM MINOR MAINT.ENANCE ON REACTOR VESSEL FLANGE, o LICENSEE THOUGHT TYGON TUBING LEVEL INDICATION UNREllABLE AND OPTED TO HAVE AN EQUIPMENT ATTENDANT VISUALLY MONITOR WATER LEVEL FROM REFUELING FLOOR, (Rx VESSEL HEAD REMOVED.)
o EA OBSERVED MINIMAL LEVEL CHANGE: HOWEVER, ACTUAL WATER LEVEL l ESTIMATED TO HAVE DROPPED TO MID-PLANE OF HOT LEG.
0 1A RHR PUMP EXHIBITED CURRENT AND FLOW OSCILLATIONS, AND WAS DECLARED IN0PERABLE, o LICENSEE REFLOODED VESSEL BY GRAVITY FEED FROM RWST THROUGH THE IB RHR PIPING TO COLD LEGS, o SHUTDOWN COOLING RESTORED USING IB RHR PUMP WITHIN 15 MINUTES, CORRECTIVE ACTIONS o LICENSEE INITIATED TRAIN'ING SESSION ON EVENT, o DRAINDOWN PROCEDURE REVISED TO REDUCE DRAIN RATE.
O LICENSEE TO ADD VESSEL LEVEL INDICATIONS IN CONTROL ROOM, i
CONTACT: P. ENG
REFERENCES:
MORNING REPORT 09/20/88
. . ~ .. ,
F0ll0WUP-o EVENTS ASSESSMENT BRANCH IS CONSIDERING ISSUANCE OF AN l ' INFORMATION NOTICE:
o REACTOR SYSTEMS BRANCH PREPARING TEMPORARY INSTRUCTION,
.0 REGION 111 PREPARING ESCAL ATED ENFORCEMENT PACKAGE.
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88-38 7
HARRIS UNIT 1 ROBINSON UNIT 2 ENVIRONMENTAL QUALIFICATION PROBLEMS WITH l TARGET ROCK SOLEN 010 OPERATED VALVES PRQg[b CRACKS WERE DISCOVERED IN THE WIRE INSULAfl0N AND TERMINAL BLOCKS OF ENVIRONMENTALLY QUAllFIED TARGET ROCK S0LEN0ID VALVES j l
C!\&L THE CRACKING 0F THE INSULATION APPEARS TO RESULT FROM CHEMICAL INCOMPATIBILITY BETWEEN THE SILICONE RUBBER INSULATION AND THE .;
POTTING COMP 0UND THE TERMINAL BLOCK CRACKING MAY RESULT FROM OVERT 0RQUE OF THE LEAD i
WlRE SCREWS EITHER BY THE MANUFACTURER OR THE LICENSEE SAFETY SIGNIFICANCE THERE IS A POSSIBILITY THAT THESE CRACKS COULD CAUSE FAILURE OF THE VALVE. THESE VALVES ARE USED IN VARIOUS SAFETY RELATED APPLICATIONS INCLUDING THE REACTOR HEAD VENT, ElSCUSSION o CRACKS IN THE LEAD WIRE INSutATION AND TERMINAL BLOCKS WERE DISCOVERED IN TARGET ROCK S0LEN010 VALVES BOTH AT HARRIS AND ROBINSON o THE LICENSEE ORDERED ENVIRONMENTALLY QUALIFIED PRODUCTS, o CRACKS WERE FOUND ON "0LDER" (NSTALLED UNITS AND ON "NEW" UNITS IN SPARES INVENTORY o THE VALVE MAY HAVE UNDERGONE ENVIRONMENTAL QUALIFICATION (E0)
TESTING WITH CRACKED LEAD WIRE INSULATION, o SEVERAL UNITS USE TERMINAL BLOCKS OF A DlFFERENT BRAND THAN THE CNE USED IN THE EQ TESTED UNIT, CONTACT: R. KARSCH (301) 492-1178
REFERENCE:
9/19/88, MORNING REPORT 9/20/88 i
88-38 2
o TARGET ROCK HAS NO RECORD OF CHANGING TERMINAL BLOCK SUPPtIER.
o AS PART OF THElR INVESTIGATION OF THESE EVENTS.THE LICENSEE VISITED TARGET ROCK AND INSPECTED THEIR RECORDS, o QUALIFICATION CERTIFICATION HAD BEEN PROVIDED F01 ALL OF THE UNITS.
o EQ CERTIFICATION IS AVAILABLE FOR UNITS WITH KAPTON INSULATED LEAD WIRES. THESE 00 NOT EXHIBli CRACKING.
CgRRECTIVE ACTION THE LICENSEE HAS ORDERED REPLACEMENT LEAD WIRES WITH KAPTON INSULATION AND WILL UPDATE THEIR EQ FILES AS NECESSARY FOLLOWUP THE VENDOR BRANCH WILL FOLLOWUP ON THIS PROBLEM TO DETERMINE IF IT IS SAFETY SIGNIFICANT, IF IT IS GENERIC 10 ALL TARGET ROCK VALVES SUPPLIED TO THE INDUSTRY AND IF AN INFORMATION NOTICE IS NEEDED.
88-38 GRAND GULF UNIT 1 TDI INTERCOOLER ADAPTER F AILURE SEPTEMBER 15, 20, 1988 PROBLEM INTERhAL DIFFUSER PLATE (GUIDE VANE) 0F THE DIVISION 2 EMERGENCY DIESEL GENERATOR DROPPED ONTO THE INTERCOOLER CAUSING IT TO LEAK.
THE DIVISION 1 INTERNAL DIFFUSER PLATE HAS CRACK INDICATIONS, CAUSE CAUSE IS UNDER INVESTIGATION, BUT IT IS BEllEVED TO BE RELATED TO FATIGUE FAILURE AT THE HEAT AFFECTED ZONE OF THE FLANGE WELD CAUSED BY ,
EXCESSIVE VIBRATION SAFETY SIGNIFICANCE THIS POTENTI AL DESIGN DEFICIENCY COULD DERATE THE EDGs OR RESULT IN MECHANICAL BINDING RENDERING THEM INOPERABLE DISCUSSION o ON SEPTEMBER 15, 1988 THE LICENSEE WAS CONDUCTING AN INVESTIGATION TO DETERMINE THE CAUSE OF JACKET WATER LEAKAGE FROM THE DIVISION 2 EDG INTAKE MANIFOLD VENT LINE o IT WAS DISCOVERED THAT AN INTERNAL GUIDE VANE OF THE LEFT BANK INTERCOOLER HAD BROKEN LOOSE FROM THE ADAPTER SHELL AND DROPPED ONTO THE INTERCOOLER TUBE BUNDLE.
o ENGINE VIBRATION CAUSED THIS PIECE TO CUT INTO THE ALUMINUM FINS AND BRASS TUBES OF THE INTERCOOLER o DISPOSITION ON DIVISION 2 WAS TO MECHANICALLY REMOVE THE PART AND MAKE WELD REPAlRS TO ADD ADDITIONAL CONNECTION SURFACE FOR THE GUIDE VANE AND TO REDUCE THE AMOUNT OF FREE STANDING VANE THAT WOULD BE SUSCEPTIBLE TO MOVEMENT o FINAL DISPOSITION ON DIVISION 1 REASONED THAT SINCE ITS LEFT BANK ADAPTER WAS REPAIRED (FEB 1984) FOR AN IDENTICAL CONDITION IT CAN PERFORM ITS REQUIRED FUNCTIONS o DIVISIONS 1. 3 EDG WERE SUCCESSFULLY STARTED AND RUN PER TECH SPECS.
88-38
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2 o ON SEPTEMBER 20, 1988 REPORTED THEIR SPECIAL INSPECTION OF THE DIVISION 1 INTERCOOLER DIFFUSER IDENTIFIED A CRACK ON THE INLET ADAPTER GUIDE VANE OF THE LEFT BANK INTERCOOLER E0LLOWUP o V-TYPE TDI DIESELS WITH DUAL TURBOCHARGER, COULD POTENTIALLY HAVE THIS PROBLEM: CATAWBA, PERRY, RANCHO SECO, RIVER BEND, SAN ONOFRE, SHEARON HARRIS, SHOREHAM, AND V0GTLE o THE LICENSEE IS CONSIDERING ISSUING A PART 21 REPORT, THE TDI OWNER'S GROUP HAS BEEN INFORMED o DIESEL INTERCOOLER LEAKS HAVE OCCURRED BEFORE, BUT TO OUR KNOWLEDGE THE PROBLEM HAS NOT BEEN STUDIED FOR GENERIC IMPACT o EAB RECOMMENDS TRANSFER OF LONG-TERM FOLLOWUP TO PLANT SYSTEMS BRANCH TO ASSESS THE GENERIC SAFETY SIGNIFICANCE CONTACT: C. SCHULTEN (301) 492-1192
REFERENCE:
EN 13497, 13502
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88-36 l , SURRY 2 THINNING OF MAIN FEEDWATER PIPING SEPTEMBER 26, 1988 PBQEL{f THE MAIN FEEDWATER PIPE NEAR A STEAM GENERATOR N0ZZLE IS THINNED TO LESS THAT THE MINIMUM ALLOWABLE THlCKNESS CAUSE EROSION / CORROSION SIGNIFICANCE FAILURE OF THE PIPE WOULD CAUSE HIGH ENERGY LINE BREAK INSIDE CONTAINMENT AND LOSS OF AUXILI ARY FEEDWATER TO THE STEAM GENERATOR DISCUSSION o ON SEPTEMBER 26, 1988. THE REGION ISSUED A PN STATING THAT ON CR ABOUT THAT DATE THINNING WAS DETECTED DURING AN INSPECTION o THE PIPE HAD BEEN INSPECTED DURING THE PREVIOUS OUTAGE o ONE SIMILAR PIPE WAS INSPECTED ON UNIT 1 LAST SPRING AND N0 UNEXPECTED THINNING WAS FOUND o ON SEPTEMBER 16, 1988, THINNING WAS FOUND ON THE SUCTION SIDE OF A MFW PUMP AT UNIT 2 o THE WALL WAS NOT LESS THAN MINIMUM ALLOWABLE BUT THINNING WAS GREATER THAN EXPECTED o EROSl0N/ CORROSION OF UNIT 2 MFW PIPING ON TliE SUCTION SIDE OF A MFW PUMP CAUSED THE CATASTROPHIC ACCIDENT OF DECEMBER 9, 1986 E0LLOWUP OEAB IS F0ll0 WING CONTACT: R. WOODRUFF (301) 492-1180
REFERENCE:
PNO-II-88-61. 9/26/88 e
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II. COMPARISON OF WEEKLY STATISTICS WITH INDUSTRY AVERAGES SCRAMS FOR WEEK ENDING 09/25/88 SCRAM CAUSE POWER NUMBER 1988 1987 1986 1985 0F WEEKLY WEEKLY WEEKLY WEEKLY SCRAMS (5) AVERAGE AVERAGE AVERAGE AVERAGE YTD (3)(4) (8)(9) o POWER >15% EQUIP. RELATED >15% 0 3.1 3.9 4.3 5.4 PERS. BELATED (6) >154 1 1.0 1.3 1.8 2.0 OTHER(7) >15% 1 0.7 1.2 0.4 0.6 o Subtotal ** 2 4.8 6.4 6.5 8.0 0 POWER <15% EQUIP RELATED <15% 2 0.7 1.2 1.4 1.3 PERS. RELATED <15% 1 0.5 0.6 0.8 0.9 DTHER <15% 0 0.2 0.3 0.2 0.2 c Subtotal ** 3 1.4 2.1 2.4 2.4 co Total *** 5 6.2 8.5 8.9 10.4 MANUAL VS AUTO SCRAMS TYPE NUMBER 1988 1987 1986 1985 CF WEEKLY WEEKLY WEEKLY WEEKLY SCRAMS AVERAGE AVER 4GE AVERAGE AVERAGE YTD MANUAL SCRAMS 1 1.0 1.4 1.0 1.0 AUTOMATIC SCRAMS 4 5.1 7.0 7.9 9.4 i 1 1
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NOTES
- 1. PLANT SPECIFIC DATA BASED ON INITIAL REVIEW OF-50.72 REPORTS FOR THE WEEK OF INTEREST. PERIOD 15 MIONIGHT SUNDAY THROUGH MIDNIGHT SUNDAY. SCRAMS ARE DEFINED AS REACTdR PROTECTIVE i ACTUATIONS WHICH RESULT IN R00 MOTION. AND EXCLUDE PLANNED
< TESTS OR SCRAMS AS PART OF PLANNED SHUT 00WN IN ACCORDANCE ! WITH A PLANT PROCEDURE. THERE ARE 109 REACTORS HOLDING AN OPERATING LICENSE.
- 2. COMPLICATIONS: RECOVERY COMPLICATED BY EQUlPMENT FAILURES OR PERSONNEL ERRORS UNRELATED TO CAUSE OF SCRAM.
- 3. PERSONNEL RELATED PROBLEMS INCLUDE HUMAN ERROR, PROCEDURAL DEFICIENCIES, AND MANUAL STEAM GENERATOR LEVEL CONTROL PROBLEMS.
- 4. "0THER" INCLUDES AUTOMATIC SCRAMS ATTRIBUTED TO ENVIRONMENTAL CAUSES (LIGHTNING), SYSTEM DESIGN, OR UNKNOWN CAUSE.
1
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