View source for PNO-III-97-010B, on 970221,plant Containment Spray Pump Found to Be Inoperable During Routine Testing.On 970307,AIT Held Exit Meeting W/Licensee.Ait Concluded That Significant Deficiencies in Oversight of Control Room Found

{{Adams
| number = ML20138F928
| issue date = 03/07/1997
| title = PNO-III-97-010B:on 970221,plant Containment Spray Pump Found to Be Inoperable During Routine Testing.On 970307,AIT Held Exit Meeting W/Licensee.Ait Concluded That Significant Deficiencies in Oversight of Control Room Found
| author name = Dapas M, Grant G
| author affiliation = NRC OFFICE OF INSPECTION &amp; ENFORCEMENT (IE REGION III)
| addressee name = 
| addressee affiliation = 
| docket = 05000295
| license number = 
| contact person = 
| document report number = PNO-III-97-010B, PNO-III-97-10B, NUDOCS 9705060098
| document type = PRELIMINARY NOTIFICATION OF EVENT OR OCCURRENCE (PNO,, TEXT-INSPECTION &amp; AUDIT &amp; I&amp;E CIRCULARS
| page count = 2
}}
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l March 7,1997 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-ill-97-010B                            i l
1 This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received without verification or evaluation, and is basically all that is known by Region ll1 staff (Lisle, Illinois) on this date.                                         I i
Facility                            Licensee Emergency Classification Commonwealth Edison Co.                        Notification of Unusual Event Zion 1                                 Alert Zion, illinois                        Site Area Emergency Dockets: 50-295                            General Emergency                                      ,
X Not Applicable                                               I l

==Subject:==
AIT TO REVIEW IMPROPER CONTROL ROD MOVEMENT DURING REACTOR SHUTDOWN (SECOND UPDATE)
The Augmented Inspection Team (AIT) reviewing the February 21 control rod movement incident at Zion Unit 1 held an exit meeting with the licensee      gp :$   ,
on March 7,1997. The meeting was open to public observation.                  g g      ;'il c
* O The team interviewed the operating shift crew which was on duty at the        8 g ;T[
time of the incident as well as a second shift crew which was present in      E         '"""
the control room assisting the primary crew. The team also interviewed licensee management who were present in the control room and who were h@
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involved in the followup activities.                                           gy    ~
In the February 21 incident, the plant was nearing the time limit for a                           ,
;      required plant shutdowr, because a containment spray pump was found to be                          ;
inoperable during routine testing. A control room operator was moving                             i control rods into the reactor core to take the reactor to a very low thermal power level, though still critical. He inserted control rods continuously for three minutes and 48 seconds which resulted in reducing power well below the intended power level. Normally, control rods would be inserted incrementally in a series of movements to allow power to be i      reduced in a controlled manner. The control rod group insertion took the reactor subcritical (i.e. shut down).
The operator then, without proper direction from operations management, began withdrawing control rods with the intent of returning the reactor to a low power level.
Before the restart occurred, however, operations management directed that all control rods be inserted to comply with the NRC license requirement requiring a shutdown because of the inoperable pump.
The AIT concluded that there were significant deficiencies in oversight of control room activities by operations supervision, in communications 9705060098 970307 PDR       I&E                                                                                q PNO-iII-97-010 PDR c/(

4 PNO-ill-97-010B                         among the control room staff, and in the execution of on-shift
;      responsibilities by the shift engineer, unit supervisor, and primary reactor operator. In addition, the actions of the reactor operator in continuously withdrawing control rods with the intent of reestablishing power reflected a significant lack of understanding of reactor physics and proper conttol rod manipulations for a controlled approach to criticality.
The team found that control room management had failed to minimize distractions in the control room and that at the time of the incident there were 15 persons in the vicinity of the areas where the reactor operator and unit supervisor were stationed. The unit supervisor and shift engineer had allowed themselves to become too involved in restoration of the containment spray pump in order to avoid the required shutdown of the reactor.
The AIT identified significant weaknesses in the communications between the operating shift crew which directly contributed to the incident.
Further, operations management did not communicate the significance of the incident to senior licensee management until the following day.
In addition, the team also found deficiencies in the licensee's licensed operator training program. Training on the actions to maintain the reactor at very low power levels is included only in the operators' initial training, and a normal reactor shutdown is not performed as part ]
of the periodic operator requalificiation training. The reactor operator at the controls during this incident received his initial training in 1985.
Unit 1 has remained shut down since the incident, having entered a planned maintenance outage previously scheduled for May. Unit 2 is in a refueling outage which began in September 1996. Region ill (Chicago) issued a Confirmatory Action Letter to the utility on February 25 documenting its agreement to investigate the incident fully and to meet with the NRC to discuss its findings before resuming operation of either unit.
The AIT inspection was focussed on gathering information about the incident. A subsequent NRC inspection will review the AIT findings to determine what, if any, violations of NRC requirements occurred.
The States of Illinois and Wisconsin will be informod of this updated information.
This information is current as of 1 p.m. CST on March 7,1997.

==Contact:==
MARC DAPAS                 GEOFFREY GRANT (630)829-9628         (630)829-9704}}

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