ML20247H223

Responds to Confirmatory Action Ltr 89-11 Re 890622 Reactor Trip.Supporting Documentation Encl.Related Correspondence

ML20247H223
Person / Time
Site:	Seabrook
Issue date:	07/12/1989
From:	Ellen Brown PUBLIC SERVICE CO. OF NEW HAMPSHIRE
To:	Russell W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
Shared Package
ML20247H229	List: ML20247H223 ML20247H267
References
CON-#389-8913 CAL-89-11, NYN-89086, OL-1, NUDOCS 8909190250
Download: ML20247H223 (33)

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NEW HAMPSHIRE YANKEE RESPONSE TO i

CONFIRMATORY ACTION LETTER 89-11 h,)

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President and Chief Execupye pfficer Edward A. IBrown u&

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^vd1 ERANL" United States Nuclear Regulatory Commission Region I 475 Allendale Road King of Prussia PA 19406 Attention:

Mr. William T. Russell References a) Facility Operating License NPF-67, Docket No. 50-443 b) USNRC Confirmatory Action Letter (CAL) 89-11 dated June 23, 1989, W. T. Russell to E. A. Brown

Subject:

New Hampshire Yankee Performance During and Following the Natural Circulation Test

Dear Mr. Russell:

This letter is in response to the USNRC Confirmatory Action Letter dated June 23, 1989. New Hampshire Yankee (NHY) provides in this letter a detailed chronology of exactly what occurred before, during and after the June 22, 1989, reactor trip, an analysis of management actions and communications during this period and a compilation of corrective actions already taken or that will be taken by NHY.

New Hampshire Yankee has conducted an Event Evaluation, an Operational Issues Evaluation and a Management Effectiveness Analysis addressing different aspects of the performance of Natural Circulation Test as well as the subsequent post-trip review and evaluation of the event.

The reports documenting these three distinct and separate evaluations are provided in Enclosures 2 through 4 respectively. Additionally, NHY Executive Management has independently reviewed the above evaluations, the conduct of the Natural Circulation Test, the post-trip review and the management actions subsequent to the event.

The conclusions of NHY Executive Management and the major corrective actions taken or planned are provided below.

The recommendations provided in Enclosures 2 through 4 have been evaluated and incorporated, as appropriate, into the short term and longer term corrective actions that have been or will be taken by NHY. A corrective action plan with a schedule for completion of all corrective actions is provided in Enclosure 1.

On June 22, 1989, a manual reactor trip of Seabrook Station, Unit 1, was initiated during the Natural Circulation Test. At no time during the transient were any technical specification parameters or design limits exceeded nor was there any danger to public health and safety, to the safety of plant personnel or to plant equipment.

New Hampshire Yankee Division of Public Service of New Hampshire P.O. Box 700 Seabrook, NH 03874 Telephone (603) 474-9521

United States Nuclear Regulatory Commission July 12, 1989 Attention:

Mr. William T. Russell Page 2 During the Natural Circulation Test the operating crew failed to follow procedures and did not trip the reactor when the pressurizer level decreased below the 172 manual trip criterion of Startup Test Procedure, 1-ST-22 Natural Circulation Test.

Operations and Startup Test management personnel who where contacted during the test by NRC inspectors regarding the 17%

reactor trip criterion did not take the appropriate actions in response to the inspectors' statements. Additionally, certain actions taken by NHY management personnel involved in the post-trip review, and certain statements made in subsequent discussions with the NRC, were inappropriate and did not reflect NHY policy.

S CONCLUSIONS The unplanned plant coo'ldown that occurred during the Natural Circulation Test was caused b/ the failure of a steam dump valve (MS-PV-30ll) positioner on the non-nuclear side of the plant.

The valve opened when the screw which fastens the valve position feedback linkage to the positioner loosened, allowing the linkage to disconnect.

The steam dump valve was the subject of maintenance work completed prior to the Natural Circulation Test.

The work request remained open however, because the follow-up post-maintenance testing had not been completed. The valve should have had this testing completed and accepted prior to the Natural Circulation Test.

The plant cooldown was subsequently terminated by closing the steam dump valve and the transient was terminated by the manual reactor trip.

Throughout this plant transient, all systems and equipment operated as would be expect 3d with the exception of the steam dump valve. A Licensee Event Report of the reactor trip will be submitted by July 24, 1989.

The Unit Shift Supervisor (USS) failed to comply with the Natural Circulation Test Procedure, 1-ST-22, by not immediately manually tripping the reactor when the pressurizer level decreased below the test's 17Z manual trip criterion.

The failure to strictly adhere to the Startup Test Procedure was an unacceptable deviation from NHY operating policy.

The Unit Shift Supervisor did not manually trip the reactor because he misinterpreted the 17Z pressurizer level value to be test termination guidance, which was more conservative than the SI pressurizer level safety injection requirement provided in Station procedures.

The pre-test briefing given to the crew performing the Natural Circulation Test was not effective.

The required information was presented to the crew but obviously the requirement to perform a manual reactor trip at 172 pressurizer level was not fully understood.

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The three NHY personnel in the Control Room, with whom the NRC personnel discussed the requirement to trip the reactor at the 17I pres-surizer level, did not respond in an effective manner.

The first two NHY personnel contacted by the NRC did not specifically recommend that the USS trip the reactor in accordance with the test procedure requirement.

The third individual contacted was about to recommend that the USS trip the reactor when the reactor was tripped.

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United States Nuclear Regulatory Commission July 12, 1989 Attention:

Mr. William T. Russell Page 3 Management personnel from the Operations chain of command were in the Control Roca during the Natural Circulation Test to observe the plant response during natural circulation.

They were not aware of the specific pressurizer level reactor trip test requirement and therefore, did not offer direction to the operating crew when the pressurizer level decreased below 17% and the reactor had not been tripped per the test procedure criterion.

The Shift Technical Advisor (STA) was acting as an additional member of the operating crew during the performance of the Natural Circulation Test.

The shift staffing arrangement would not have delayed his assuming the functions of the STA, if such action had been required.

However, the manning of the STA position will be re-evaluated to ensure that there are no potential conflicts to prevent STAS from assuming their duties.

The four hour verbal report made to the NRC per 10 CFR 50.72 was not precisely worded, and contained inaccurate information and consequently, contributed to the miscommunication between NHY and the NRC. While there was no intent to mislead the NRC, the communication inaccurately reported

'While performing low-power physics testing. Startup Test Procedure 1-ST-22 Rev. #2 (Natural Circ) Tavg had reduced to below 541'F, pressurizer pressure at 2340 psig and pressurizer water level less than 17%.

These were manual trip criteria per procedure. MS-P3011 stuck open causing initial cooldown."

The information provided in the four hour report should have conveyed the following The Natural Circulation Test was not part of low-power physics testing.

The pressurizer level had been less than 17%, which was a manual reactor trip criterion per the test procedure, but had been recovered to 21% at the time of the manual reactor trip.

The pressurizer pressure had not reached the manual trip criterion of 2340 psig. The manual reactor trip was initiated at 2310 psig with pressurizer pressure increasing.

The reactor coolant temperature as indicated by Tavg had been less than 541*F for approximately five minutes when the manual reactor trip was initisted.

The criterion in the procedure is to restore Tavg to greater than 541*F within 15 minutes or be in Hot Standby within the next 15 minutes.

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United States Nuclear Regulatory Commission July 12, 1989 Attention:

Mr. William T. Russell Page 4 Subsequent to the reactor trip, New Hampshire Yankee management took action to initiate a review of the Natural Circulation Procedure and the policies on procedure compliance. However, NHY management personnel who participated in the 1800 conference call with NRC Region I on June 22nd had not completed their analysis of the event and therefore did not yet have sufficient information to completely discuss the procedural non-compliance problem and the proposed corrective actions.

In addition to being unable at that time to discuss specific details on the procedural inadequacies and the corrective actions:

NHY management did not effectively communicate to the NRC their recognition of the seriousness of the procedure noncompliance and the actions planned to prevent recurrence.

Statements nade by some NHY personnel, which supported the actions taken or not taken by the operating crew, were inappropriate and did not represent the NHY procedure compliance policy.

Statements made by some NHY personnel, which indicated NHY was considering restarting the reactor prior to the completion and evaluation of a total event analysis, were inappropriate and did not accurately represent NHY policy and the understanding of the NHY President.

MAJOR CORRECTIVE ACTIONS On June 22nd, following the reactor trip, the Vice President - Nuclear Production directed the Station Manager to ensure that all operating personnel were aware of the NHY policy on procedure compliance.

The Operations Manager met with each shift crew and reviewed the policy.

This action was completed on June 29, 1989, when the relief crew returned to duty.

New Hampchire Yankee Executive Management ordered the plant cooled down to MODE 5 and postponed a maintenance related turbine-generator torsional test.

The turbine-generator test requires the plant to be at operating temperature and pressure, ard was scheduled to be completed after the low power testing program concludad. These actions were taken to allow the appropriate evaluations to be performed and to ensure that all retuired corrective actions are completed prior to reinitiating any major integrated plant testing.

The cooldown was completed at 1254 on June 28, 1989.

l The NHY policy on procedure compliance was reviewed and revisions were made to ensure that a misinterpretation, such as occurred during the Natural Circulation Test, will not be repeated. The initial revision to the Seabrock Station Management Manual was reviewed by the Station Operation Review Committee on June 28, 1989, and approved by the President on July 5, 1989. On July 10, 1989, the NHY President issued a memorandum to all site employees emphasizing the NHY policy on procedure adherence and the significance that NHY management places on adherence to the policy.

____.___.___.---m.-_-__.__---______.__-_____m__.__

United States Nuclear Regulatory Commission July 12, 1989 Attention:

Mr. William T. Russell Page 5 On June 29th, the Vice President-Nuclear Production was relieved of his duties at Seabrook Station and he subsequently resigned from Public Service Company of New Hampshire. He was relieved of his duties due to the inappropriate actions that he took directly and allowed to occur following the reactor trip.

The actions primarily concern communications with the NRC during the 1800 conferen'ce call on June 22nd as well as subsequent incomplete communications with the President of New Hampshire Yankee regarding the subjects covered during that conference call.

Those individuals who reported to the Vice President - Nuclear Production ncw report temporarily to the President. Organization changes will be made in the near future and will be provided to the NRC on or before July 28, 1989.

Additional disciplinary action has been taken in the form of letters of reprimand issued by NHY management to:

the management personnel in the Operations chain of command who were present in the Control Room during the test, the personnel who were spoken to by the NRC inspectors regarding the 172 pressurizer level trip criteria during the test, and the operators and engineers on the shift crew involved in the test who had the authority or the responsibility to prevent the procedure violation.

The Nuclear Safety Audit Review Committee has reviewed the event and the corrective action plan and concurs with the evaluation and the proposed corrective actions.

The Startup Test Program will be revised to require that a more comp-rehensive pre-test briefing be provided prior to the test crew assuming the shift.

In addition, the Startup Test Program will be reviewed to determine which tests require special classroom review and/or simulator rehearsals for the test crews prior to the test being conducted.

The NHY policy related to procedure compliance will be further improved to better define the conduct expected of all NHY personnel related to procedure compliance, and training will be provided to all NHY personnel on the enhanced NHY procedure compliance poliev.

The failure of steam dump valve (MS-PV-3011) will be evaluated and corrective action will be taken to repair the valve.

The open Work Request on the steam dump valve will be completed and the Startup Test Program procedures will be revised to preclude recurrence of a similar situation.

SUMMARY

New Hampshire Yankee personnel failed to follow procedures by not strictly adhering to the criteria specified in the Startup Test Procedure, Natural Circulation Test, (1-ST-22).

Additionally, certain other actions taken by NHY management were inappropriate.

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United States Nuclear Regulatory Commission July 12, 1989 Attention:

Mr. William T. Russell Page 6 There was inappropriate management action in communications with NRC Region I personnel regarding recognition of the seriousness of the procedure non-compliance problem, statements in support of the operating crew's actions and statements indicating a readiness to restart the reactor.

New Hampshire Yankee recognizes the severity of the procedure non-compliance t

and has evaluated the circumstances and conditions surrounding the event.

Additionally, NHY recognizes.the seriousness of the statements made and the impressions conveyed to the NRC during the 1800 conference call on June 22nd. Corrective action will be completed prior to NHY conducting additional major integrated plant testing and prior to commencing the power escalation testing program.

The Chief Executive Officers of the Joint Owners of Seabrook Station recognize the seriousness of the procedure non-compliance and subsequent events.

The Executive Committee of the Joint Owners has had three separate meetings with NHY Executive Management to review the events, the corrective actions proposed and the proposed responses to the NRC.

I have personally met with the senior managers in the Operations chain of command and have clearly reinforced the responsibilities and requirements that are intrinsic in their assigned positions.

I firmly believe that the NHY policy on procedure compliance is understood and will be adhered to by all NHY personnel.

New Hampshire Yankee recognizes the responsibility and trust that the NRC conveyed to NHY with the issuance of an operating license.

It is the NHY mission to meet those responsibilities and NHY is committed to taking the actions that are necessary to regain that trust.

New Hampshire Yankee is prepared to discuss the events associated with the Natural Circulation Test, this evaluation and the resulting corrective actions with the NRC Staff. Additional information such as the Station Information Report and related data are available at Seabrook Station for your review.

Should you have any questions regarding this matter, please contact me at (603) 474-9521.

Very truly yours, Edward A. Brown President and Chief Executive Officer

United States Nuclear Regulatory Comission July 12, 1989 Attention:

Mr. William T. Russell Page 7 cca Document Control Desk United States Nuclear Regulatory Comission Washington, DC 20555 Mr. Victor Nerses, Project Manager Project Directorate I-3 United States Nuclear Regulatory Comission Division of Reactor Projects Washington, DC 20555 NRC Senior Resident Inspector P.O. Box 1149 Seabrook Station, NH 03874 ASLB Service List-f

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E ENCLOSURE 1 TO NYN-89086 CORRECTIVE ACTION PLAN 4.

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ENCLOSURE 1 TO NYN-89086 CORRECTIVE ACTION PLAN New Hampshire Yankee Executive Management reviewed the Natural Circulation Tests the actions taken prior to, during and after the test; and the three

- independent evaluations provided in Enclosures 2 through 4.

As a result of these reviews and numerous interviews the following compilation of short term and longer term corrective actions was developed to correct identified weaknesses and to ensure that events similar to that of June 22, 1989, do not recur.

The recommendations provided in Enclosures 2 through 4 have been evaluated and incorporated into this corrective action plan as appropriate.

SHORT TERM CORRECTIVE ACTIONS Procedure Compliance Hold meetings with each of the shift crews to review the policy on I

procedure compliance..

COMPLETED:

June 29, 1989 Revise and reissue the procedure compliance policy in the Seabrook Station Management Manual to more clearly state that procedures are to be followed when operating Seabrook Station unless an overriding safety concern prohibits such action.

COMPLETED:

July 5, 1989 Issue a memorandum from the NHY President to all personnel working at Seabrook Station re-emphasizing the requirement that all procedures are to be followed.

COMPLETED:

July 10, 1989 Enhance the Seabrook Station Management Manual procedure compliance policy to clearly specify that the only conditions under which departure from approved procedures is allowed is when such action is required to protect the public health and safety, personnel safety or to prevent serious damage to plant equipment.

SCHEDULED COMPLETION DATE: July 31, 1989 Develop and issue a comprehensive NHY policy to clearly define procedure adherence requirements for all NHY activities.

SCHEDULED COMPLETION DATE: August 15, 1989 Develop and issue an NHY policy statement on Core Values and Work Ethics.

SCHEDULED COHPLETION DATE: July, 21, 1989 i

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Command and Control Relieve the Vice President - Nuclear Production of his duties related to Seabrook Station.

COMPLETED: June 29, 1989 Issue letters of reprimand to the management personnel in the Operations chain of 'ommand who were present in the Control Room c

during the test, the personnel who were spoken to by the NRC inspectors regarding the 17% pressurizer level trip criterion during the test, and to the operators and startup engineers on the shift crew involved in the test who had the authority and responsibility to prevent the procedure violation.

COMPLETED:

July 11, 1989 Replace the Vice President - Nuclear Production.

SCHEDULED COMPLETION DATE:

July 28, 1989 Hardware Inspect and evaluate the steam dump valves to determine the cause of the failure, the required corrective action and a schedule for completion of the corrective action.

SCHEDULED COMPLETION DATE:

July 28, 1989 LONGER TERM CORRECTIVE ACTIONS a

Procedure Compliance Provide training to all NHY personnel on the enhanced NHY procedure compliance policy.

SCHEDULED COMPLETION DATE:

October 6, 1989 Procedure Development Review 1-ST-22, ' Natural Circulation Test" to provide further instruction regarding initial conditions and to determine the ability to perform the test with the controls in automatic.

SCHEDULED COMPLETION DATE: August 18, 1989 Review the Startup Test Program and remaining Startup Test Procedures and revise as appropriate to incorporate the guidance which currently exists in the Station Management Manual and other applicable NHY manuals and to ensure the test procedure format and guidance is consistent with current Station Operating Procedure guidance.

SCHEDULED COMPLETION DATE:

September 15, 1989 2

h Reorganize Operations to provide personnel to perform the required development, periodic reviews and consistency reviews of Operations procedures.

SCHEDULED COMPLETION DATE:

September 29, 1989 Test Process Revise the Startup Test Program to remove the reactivity computer from the horseshoe area when it is not required for testing.

SCHEDULED COMPLETION DATE:

September 1, 1989 Revise the Startup Test Program to require that a more comp-rehensive pre-test briefing be provided prior to the test crew assuming the shift to ensure that the crew understands the test criteria, expected parameters and required actions.

SCHEDULED COMPLETION DATE:

September 1, 1989 Revise the Startup Test Program to require that additional preparation, including simulator rehearsals when feasible, be given to test crews assigned to perform complex tests.

SCHEDULED COMPLETION DATE:

September 1, 1989 Revise the Startup Test Program to provide controls to ensure that all relevant Work Requests are closed out prior to the initiation of tests that utilize the relevant equipment for example, steam dump valves on the non-nuclear side of the plant.

SCHEDULED COMPLETION DATE:

September 1, 1989 Revise the Startup Test Procedure to provide additional guidance for terminating the test and exiting the test procedure when equipment malfunctions or plant transient occur during testing, SCHEDULED COMPLETION DATE:

September 1, 1989 Command and Control Establish a shift minning policy to ensure that the Shift Technical Advisor will not have collateral duties other than as the Unit Shift Supervisor or Shift Superintendent.

SCHEDULED COMPLETION DATE: AUGUST 15, 1989 Revise the Operations Management Manual to:

1) Clarify the integration of Startup Test personnel with the shift operating crew,

2) Clarify responsibility and authority when supplemental operators are assigned to a shift, 3

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3) Encourage non-shift licensed Operations personnel to provide a point of clarification or information when an assigned operator's actions appear to be inappropriate or are not understood by the observer.

4) Require the Operations management licensed personnel to define their responsibilities when they enter the horseshoe area of the Control Room during testing.

SCHEDULED COHPLETION DATE: August 18, 1989 Revise the policy on Control Room Access to establish the maximum number of personnel allowed in the Control Room and the horseshoe area of the Control Room.

SCHEDULED COMPLETION DATE: August 18, 1989 Human Factors Appoint a Human Performance Evaluation System (HPES) Coordinator and implement the INPO HPES Program.

SCHEDULED COMPLETION DATE: October 31, 1989 Post-Trio Review Revise the Startup Test Program for power ascension testing to require the Event Evaluation Report to be completed prior to recommending reactor restart.

SCHEDULED COMPLETION DATE: August 31, 1989 Revise the Post-Trip Review procedure to assign an individual as the NRC contact during the review process and to include a discussion of the trip with the NRC prior to reactor restart.

SCHEDULED COMPLETION DATE: August 31, 1989 Review the NHY Reporting Manual to deterndne if additional guidance is required for 10CFR50.72 reporting.

SCHEDULED COMPLETION DATE September 15, 1989 Review the Event Evaluation procedure to determine if enhancements are required concerning the post-trip review, assignment of personnel, post trip critiques and written chronologies.

SCHEDULED COMPLETION DATE:

September 15, 1989 l

Hardware Complete a Licensee Event Report to include a 10CFR50.59 analysis of the Natural Circulation Test and reactor trip.

SCHEDULED COMPLETION DATE: July 24, 1989 4

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Re-evaluate the routine maintenance frequency and the post-maintenance testing criteria for the steam dump valves.

SCHEDULED COMPLETION DATE: August 31, 1989 Evaluate the effect of the Natural Circulation Test on the charging nozzle and develop a schedule for any corrective action.

SCHEDULED COMPLETION DATE: August 31, 1989 Y

Examine valves similar to the steam dump valves to determine if similar conditions exist, and develop a schedule for any corrective action.

SCHEDULED COMPLETION DATE: August 31, 1989 Evaluate the maintenance program to ensure that sufficient emphasis is placed upon post-maintenance testing and visual inspections.

SCHEDULED COMPLETION'DATE: August 31, 1989 Evaluate the methods used to operate the letdown isolation valve to determine the effects of any flashing that occurred during the test.

Develep operating techniques to ensure the water does not flash to steam.

SCHEDULED COMPLETION DATE:

September 30, 1989 Management Oversight Evaluate the effectiveness of the NHY procedure compliance policy upgrade by means of a combination of audits and surveillance to verify and' assess the implementation of the policy, and provide a report to the President.

SCHEDULED COMPLIANCE DATE: October 31, 1989 l

5

ENCLOSURE 2 TO NYN-89086 EVENT EVALUATION REPORT Manual Reactor Trip During 1-ST-22, Natural Circulation Test

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EVENT EVALUATION REPORT Manual Reactor Trip During 1 ST-22, Natural Circulation 1kst Initial Conditions Event Date: June 22,1989; 12:19 pm to 12:36 pm. The following control systems were in manual control:

Pressurizer Pressure Pressurizer Level Steam Generator Level Steam Dump Rod Control Reactor Power at 1.8 x 10 amps on the intermediate range detectors (conservatively estimated to be 3% power). Group A turbine drains and main steam upstream drains open.

Chronological Summary of Events (time from station computer) 12:18:50 Reactor coolant pumps tripped to initiate test. All steam generator water levels were within 50% to 55%. As expected, pressurizer level and pressure increased slightly as average reactor coolant temperature increased due to loss of forced circulation.

Pressurizer level and pressure then began to decrease as one loop transport cycle was completed. Since steam dump was in manual, the loss of reactor coolant pump heat input was not offset by a corresponding decrease in steam demand. Reactor power began to decrease due to the effects of the doppler (or fuel) temperature coefficient.

The combination of zero moderator temperature coefficient (an initial condition for the test) and slightly negative doppler (or fuel) temperature coefficient resulted in a negative overall temperature coefficient that was reflected in hot leg temperature. Hot leg temperatures were expected to change in proportion to average fuel temperature.

12:24:56 The condenser dump valves isolated due to the Lo Lo Tavg interlock @ 550 F This was expected since narrow range Tavg signals would be unreliable after the reactor coolant pumps were tripped and would decrease. The interlock was bypassed via the normal main control board switches to regain control of the cooldown bank of the steam dump valves; MS-PV-3011, MS-PV 3015 (block valve closed), and MS PV 3019.

When the interlock was bypassed, the valves tried to return to their pre interlock demand position (-5%, i.e. minimum). MS-PV-3019 was open for approximately 40 seconds before finally closing. During this time, steam generator levels started to swell in response to increased steam demand. This increased demand accelerated the decreasing pressurizer pressure and level trends.

12:26:04 Approximately 6 seconds after MS-PV-3019 went closed, MS-PV-3011 went full open (verified by local observation). By design, one steam dump valve is expected to handle approximately 3.3% steam demand. Main steam drains were closed at 12:27 to eliminate some of the secondary demand. Hot leg temperatur(s started to decrease and the reactor power decrease stopped. Pressurizer pressure and level continued to decrease due to the steam demand even though letdown was at minimum (10 gpm) and charging was almost at maximum (122 gpm).

-/.

12:28:53 Pressurizer level decreased below 17%, which is a 1-ST-22 manual trip criterion (the operating procedures require a safety injection for pressurizer level below 5%). The control system isolated letdown and tripped pressurizer heaters. Letdown flow indication began to show evidence of flashing in the isolated line. Pressurizer pressure was 2206 psig and continued to decrease. Reactor power level started to increase at an extremely slow rate and was approximately 2%, which was still below the initial value.

12:31:06 Steam dump valve MS-PV 3011 was closed by taking steam dump interlock control to.

OFF. As steam demand was terminated, steam generator levels shrank approximately 4%. Pressurizer level reached 14.5% which was its minimum value during the transient. Pressurizer pressure reached its corresponding minimum of 2179 psig. With charging at approximately 122 gpm (approximately 1% level / minute), letdown isolated and no steam demand, pressurizer level and pressure began to rapidly recover.

12:33:57 The pressurizer low level letdown isolation and heater interlock reset when pressurizer level returned above 17%. Pressurizer pressure was recovering rapidly at 2258 psig. Reactor power leveled off at approximately 2.5% which was still below the initial values.

12:35:54 Pressurizer level was at 21% and increasing about 1.5 %/ minute. Pressurizer pressure was at 2310 psig and had been increasing at a rate of approximately 30 psig/ minute.

Post trip data analysis showed that the rate of pressure increase was slowing but would not yet have been apparent to the operators. The Unit Shift Supervisor ordered a reactor trip prior to reaching a 1 ST 22 manual trip criterion of 2340 psig (the automatic reactor trip setpoint is 2385 psig). The operating crew immediately entered Emergency Procedure E-0, Response to Reactor Trip, and proceeded without incident.

Summary Table of Major Parameters Parameter, Initial

'IYansient Transient Trip Criteria Units Value Min. Value Max. Value Normal 1 ST 22 Reactor Power,%

3%"

est 1.5%

est 2.5%

>25

>5 Pzr Pressure, psig 2237 2179 2310

>2385

>2340 Pzr Level, %

25 14.5 25*

<5

<17 Charging Flow, gpm 70 70*

125 letdown Flow, gpm 60 0

60*

Wide Range Thot, *F 557 554 572 Wide Range bid, *F 554 522 554*

Wide Range Tavg, 'F 556 539 560

>585 S/G narrow range level,%

53 48 57

<14

" intermediate range

• Initial value A calorimetric calculation of data obtained prior to the reactor coolant pump trip showed initial reactor power to be 74 MWt or 2.2%.

2

Post Trip Troubleshooting of MS PV 3011 At approximately 1300 the Operations Department issued a work request to have the Instrument and Control Department investigate the behavior of steam dump valve MS PV 3011. The investigation of the valve found that the valve position feedback linkage was disconnected from the positioner. The disconnected linkage resulted from two causes:

The screw connecting the positioner arm to the connecting link assembly is not long enough to allow the connecting nut to have full thread engagement.

Examination of valves MS-PV-3015 and MS PV 3019 found the feedback linkages to be intact, but loose on MS PV-3019. The loose linkage was tightened.

The ball joint on the connecting linkage was stiff, causing the screw and nut to rotate when the valve was stroked. This eventually resulted in the nut loosening and falling off.

After the linkage was connected, the technicians attempted to calibrate the positioner by stroking the valve. During these attempts the valve was observed to stick at approximately 50% to 75% travel, and again at approximately 20% when given a signal to close. When control air was fully bled off, the actuator spring would force the valve to slam shut. The shift mechanical engineer found that the actuator was pulling the stem to one side as the valve was stroked, causing mechanical binding. Valve testing also showed that once the actuator is misaligned, binding worsens with successive valve movements.

Conclusions The difficulties encountered during perfonnance of 1-ST 22 resulted from the following events:

Cooldown due to MS-PV-3011 going full open.

Steam demand (dump and drains) remained in manual at pre-RCP trip values that could not be maintained by the reactor. This was a minor effect in comparison to MS-PV 3011 opening.

With steam dump controls in manual, steam demand remained constant. The continuing steam demand started a cooldown that was disguised in its early stages because cold leg temperatures were expected to initially decrease up to 5 'F which would cause ailinitial pressurizer outsurge.

When MS-PV 3011 went full open, the higher steam demand caused pressurizer level to decrease at a rate faster than the charging system could maintain. This cooldown continued until MS-PV-3011 was closed. This effect is clearly demonstrated on the charts produced during post trip analysis. MS-PV-3011 went fully open due to the positioner feedback linkage becoming disconnected. Without position feedback, any demand to open from the control system would result in the valve continuing to travel to the full open position. Since several observers saw MS-PV-3011 position indication behaving as expected early in the test, and the plant computer shows several cycles of operation, it is concluded that the linkage did in fact become disconnected during the test after valve movement and vibration caused the nut to fall off.

Analysis of the data acquired by the GETARS during the test, discussions with the test crew, the operating crew, and the technicians involved in the troubleshooting, lead to the overall conclusion that:

1.

The plant responded as would be expected for the conditions and events experienced. The change in pressurizer level was due to the change in reactor 3

coolant system average temperature (the procedure noted that level could be expected to change approximately 1%/ F change in Tavg). Pressurizer level dropped 11% while Tavg dropped 16 F. Deviations from the 1%/*F approximate conversion are attributable to the difn.rence between constant RCS mass assumed in the conversion, and increasing RCS mass (due to max. charging and isolated letdown) during the event.

2.

There are no unexplained events or phenomena. The cooldown was caused by dump valve PV-3011 going open. The observed behavior of steam dump valve PV-3011 is attributable to the disconnected linkage and mechanical binding found by the technicians.

Recommendations:

Short Term:

1.

Manual trip criteria listed in 1 ST.22 were exceeded for several minutes before a manual trip was initiated. Develop an NHY policy on procedure compliance, including training, that clearly defines the requirements to follow procedures.

2.

The condition of positioner feedback linkages should be checked for all steam dump valves.

3.

1 ST 22 should be modified to provide further instruction doout the initial conditions relating to steam demand and the necessity for balancing demand to power level. Conditions for 1-ST-22 should also be re-evaluated to determine the ability to perform the test with control systems in automatic.

4.

Test Directors and Shift Test Directors should be reminded of the need for active, vigorous recommendations when test criteria or conditions are exceeded.

Long Term:

1.

Maintenance programs should be evaluated to insure that sufficient emphasis is placed on post-maintenance testing and routine visual inspections.

2. Evaluate the design of the feedback linkage connection to determine if there is a more secure means of fastening the linkage.

3.

The RTS for steam dump valve positioner calibration is currently on a two year interval and requires NOP/NOT conditions for performance. This interval should be examined to determine if it is adequate. The feasibility of testing positioner calibration at conditions other than NOP/NOT should also be evaluated.

4.

All steam dump valves should be examined to determine if binding due to actuator problems exists and what changes may be appropriate to eliminate such binding.

5.

Determine if there are other valves on site that might be subject to similar linkage or binding problems.

6. Evaluate the thermal effects of the transient on the charging nozzle.

7.

Evaluate letdown isolation valve operation in order to avoid flashing.

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v ENCLOSURE 3 TO NYN-89086 OPERATIONAL ISSUES EVALUATION Natural' Circulation Test, 1-ST-22

ENCLOSURE 3 TO NYN-89086 OPERATIONAL ISSUES EVALUATION OF THE NATURAL CIRCULATION TEST (1-ST-22) ON JUNE 22, 1989 New Hampshire Yankee (NHY) conducted a review and analysis of the Natural Circulation Test performed on June 22, 1989, to assess personnel actions taken during the performance of the test. Related operational issues were assessed from a human performance standpoint and recommendations were developed for short-term and long-term corrective actions.

This review did not include a technical assessment of the Natural Circulation Test.

The review and analysis was performed by personnel from the NHY Training Group. The scope of the review and analysis concentrated on the pre-test briefing and the conduct of the test.

The following performance factors were addressed:

Operator awareness at the main control board, Transient diagnosis, Actions during the transient, Use of Procedures, Communication, and Teamwork.

Interviews were conducted on June 23rd, 24th and 25th with the eleven individuals who were directly involved in the conduct of the Natural Circulation Test.

The interviews were conducted utilizing standard questions in a one-on-one format to promote open discussions and a frank exchange of information and opinions while providing confidentiality for the interviewee.

The conclusions and recommendations provided in this report reflect the interviewers' consolidation of data. As a result of the analysis human performance was categorized into the following four areas:

Procedures Startup Test Program Command and Control Human Performance 1

__-__m___

Procedures There existed a difference of understanding between the Operations and Startup Test Department personnel regarding aspects of the Startup Test Procedure 1-ST-22 Natural Circulation Test. Operations personnel considered the 17Z pressurizer level reactor trip provided in the Startup Test Procedure to be conservative guidance for the conduct of the test and not a requirement such as the 5Z pressurizer level safety injection trip provided in the Station procedures.

The Startup Test Procedures are not written in the same format as required by procedure SM 6.2, Station Operating Procedures, and do not specify requirements in a manner that Operations personnel frequently utilize. Additionally, the Operations personnel did not have the degree of control over the Startup Test Procedures that they do over Station Operating Procedures due to the different development processes. However, Startup personnel appeared to be comfortable with the dual procedure system and would have treated all procedures equally.

The following recommendations are provided to address the procedure Concernst 1.

Clarify the procedure compliance policy so that it clearly states the requirements to strictly follow all applicable procedures while operating or testing the Station.

2.

Revise the procedure development process to require that Startup Test Procedures follow the Station Operating Procedure development process and be consistent with the Station Operating Procedures with regards to wording and presentation of requirements.

3.

Expedite the current management initiatives to reorganize Operations to provide dedicated personnel to perform the required development, periodic reviews and consistency reviews for Operations procedures.

Startuo Test Program Prior to and during the Natural Circulation Test, factors were present in the Control Room which could have had an effect on the performance by Operations and Startup personnel. A large number of personnel were in the control room to observe the test including personnel from offshift Operations. Training, NHY management and the NRC.

The reactivity computer was located in the center of the horseshoe area and made communications between Operators somewhat more difficult. Additionally, preparations were underway to prepare for the maintenance related turbine-generator torsional test once the low power testing was complete.

2

= ___

1 The following recommendations are provided to address the human performance factors-regarding the Startup Test Program

-l 1.

Establish;a'Startup Test Program policy to remove.the reactivity j

computer when it is not required for physics testing.

I 2.

Establish a policy that requires each complex test evolution to be' 1

performed by an experienced test crew and operating shift crew who

{

have reviewed the test'as a team, and performed the evolution in i

the. simulator if appropriate.

3.

Establish's. testing policy to require that more extensive pre-test 1

briefings for complex tests.be conducted prior.to the designated test' crew assuming the' shift including.tne criteria which ensure j

that. applicable plant parameters are maintained within the test

]

' boundaries and the action to be taken if test parameters are

-exceeded.

Command and Control Prior to the reactor trip, the operators either focused on one indication or had reduced communications compared to normally expected responses. One:of.the factors that could have contributed to this situation j

was' lack of familiarity with the shift crew organization of five crew q

members used for the Natural Circulation Test. Under most conditions,

)

operators function in a crew of.three members.

The additional two members l

in the shift crew made the reporting relationships, lines of authority, and l

communications more complex.

]

i The following recommendations are provided to enhance the command and control human performance factors:

1.

Revise-the Operations Management Manual to more clearly define the I

roles of extra personnel on an operating shift.

2.

Revise the Operations Management Manual to provide additional guidance regarding communications with a shift composition other than the " normal three operators".

I 7

i 3.

Revise the policy on Control Room Access to establish the maximum number of personnel allowed in the Control Room and the actual control board area.

4.

Revise the Operations Management Manual to clarify the role of Operations management when they enter the horseshoe area of the Control Room during testing.

1 1

1

-i l

\\

3 p

l 1

L 1

t Human Performance-l

[.

-The manual' reactor trip.was not initiated at the time specified in the

(

. Natural Circulation Test Procedure.(1-ST-22), and is clearly a case of procedural noncompliance.

The dominant reason given-for not tripping the

' reactor is that the Operations personnel considered the Startup Test Procedures to define's set of conservative test parameters, and not to

~

establish requirements that superceded.the Station procedures or the Technical Specifications.

The result was that the operating crew failed to ffollow a" procedure due to a misinterpretation of the procedure compliance j

. requirement as it applied to'the reactor trip. criteria of the Natural E

Circulation Test Procedure.

The following' human factors recommendation is provided to establish a system'to systematically evaluate human performance problems and establish corrective actions to prevent'their recurrence

. Appoint a Human Performance Evaluation System (HPES) Coordinator and implement the INPO HPES Program as a continuing NHY evaluation program.

Summary The human factors evaluation interviews conducted subsequent to the reactor trip concluded that the personnel involved in the Natural Circulation Test recognized that a procedure compliance violation had occurred. While the test was being performed, however, an understanding of the need for verbatim compliance to the Startup Test Procedure was not the case and the Operating crew believed that they were taking the necessary actions to keep the plant within its normal operating parameters and in a safe condition at all times.

4 1

i

}

}

ENCLOSURE 4 TO NYN-89086 MANAGEMENT EFFECTIVENESS ANALYSIS REPORT Natural Circulation Test, Manual Reactor Trip and Followup Actions