ML17263A511

LER 93-007-00:on 931122,RT Occurred Due to High Source Range Flux Level During Reactor Startup.Caused by Failure of Personnel Focusing on Rt Setpoint.Replaced Status Lights & Corrected PPCS Alarm message.W/931222 Ltr

ML17263A511
Person / Time
Site:	Ginna
Issue date:	12/22/1993
From:	Martin J, Mecredy R ROCHESTER GAS & ELECTRIC CORP.
To:	Andrea Johnson NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM), Office of Nuclear Reactor Regulation
References
LER-93-007, LER-93-7, NUDOCS 9401110017
Download: ML17263A511 (18)

Text

ACCELERATED DISTRIBUTION DEMONSTRATION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9401110017 DOC.DATE: 93/12/22 NOTARIZED: NO DOCKET FACIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH.'AME AUTHOR AFFILIATION MARTIN,J.T. Rochester Gas & Electric Corp.

MECREDY,R.C., Rochester Gas & Electric Corp.

RECIP.NAME RECIPIENT AFFILIATION Project Directorate I-3 R'OHNSON,A.R.

I

SUBJECT:

LER 93-007-00:on 931122,RT occurred due to high source range D',

flux level during reactor startup.Caused by failure of personnel focusing on RT setpoint.Replaced status lights &

corrected PPCS alarm message.W/931222 ltr. $

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:

TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

A NOTES:License Exp date in accordance with 10CFR2,2.109(9/19/72). 05000244 D

RECIPIENT COPIES RECIPIENT COPIES D, ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD1-3 LA 1 1 PD1-3 PD 1 1 JOHNSON,A 1 1 INTERNAL: AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DE/EELB 1 1 NRR/DE/EMEB 1 1 NRR/DORS/OEAB 1 1 NRR/DRCH/HHFB, 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRIL/RPEB 1 1 NRR/DRSS/PRPB 2 2 QB~RDSSQ/D PLB 1 1 NRR/DSSA/SRXB 1 1 1 1 RES/DSIR/EIB 1 1 1 1 EXTERNAL EG&G BRYCE g J ~ H 2 2 L ST LOBBY WARD 1 1 NRC PDR .1 1 NSIC MURPHYgG A ~ 1 1 NSIC POORE,W. 1 1 NUDOCS FULL TXT 1 1 D

D D

NOTE TO ALL "RIDS" RECIPIENTS:

S PLEASE HELP US TO REDUCE lVASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOibl PI-37 (EXT. 20079) TO ELIiVIINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!

-FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 28 ENCL 28

r ion K .

ssssr ROCHESTER GAS AND ELECTRIC CORPORATION e 89 EAST AVENUE, ROCHESTER N. Y. 14649-0001 R6BERT C, MEGREOY TELEPHONE Vice Presiden< AsrEA CODE 716 546 2700 Cinna Nuclear Produriion December 22, 1993 U.S. Nuclear Regulatory Commission Attn: Allen R. Johnson Project Directorate I-3 Document Control Desk Washington, DC 20555

Subject:

LER 93-007, High Source Range Flux Level During Reactor Startup Causes a Reactor Trip R.E. Ginna Nuclear Power Plant Docket No. 50-244 In accordance with 10 CFR 50.73 I Licensee Ev en t R epor t System,

~

item (a ) (2 ) iv who.ch requires a report of, "any event or (zv),

condition that resulted in a manual or automatic ct e y feature (ESF), including the reactor protection t'a system (RPS)", the attached Licensee Event Report LER 93-007 07 1s hereby submitted.

Thxs event has in no way affected the public's health and safety.

Very truly yours, Robert C. Mecredy XC U.S. Nuclear Regulatory Commission Region I 475 Allendale Road King of Prussia, PA 19406 Ginna USNRC Senior Resident Inspector 0 60053.

9401>~OOX7 93>~~>

PDR ADQCK 050002 POR

NRC FORH 366 U.S. II)CLEAR REGULATORY C<NNIISSION APPROVED BY QGI NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY lllTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

LICENSEE EVENT REPORT (LER) FORHARD COMMENTS REGARDIHG BURDEN ESTIMATE TO THE IHFORHATIOH AND RECORDS MANAGEHENT BRANCH (HNBB 7714), U.S. NUCLEAR REGULATORY COMHISSIOH, (See reverse for required number of digits/characters for each block) NASHINGTOH, DC 20555-0001 AND TO THE PAPERUORK REDUCTION PROJECT (31/0-0104), OFFICE OF MAHAGEHENT AND BUDGET NASHINGTON DC 20503-FAclLITY lQ% (1) R. E ~ Ginna Nuclear Power Plant DOCKET NQIBER (2) PAGE (3)

=05000244 1 OF 7 TITLE (4) High Source Range Flux Level During Reactor Startup Causes a Reactor Trip EVENT DATE 5 LER INNBER 6 REPORT DATE 7 OTHER FACILITIES INVOLVED 8 SEQUENTIAL REVISION FACILITY NAHE DOCKET NUMBER MONTH DAY YEAR YEAR MOHTH DAY YEAR HUHBER NUMBER 11 22 93 93 --007-- 00 12, 22 FACILITY HAME DOCKET NUMBER STRAYING THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR  : Check one or more 11 INXIE,(9) N 20.402(b) 20.405(c) 50.73(a)(2)(iv) 73.71(b)

POUER 20.405(a )(1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c) 000 50.73(a)(2)(vii)

LEVEL (10) 20.405(a)(1)(ii) 50.36(c)(2) OTHER 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) (Specify in 20.405<a)(1)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) Abstract beioM and in Text, 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)<2)(x) HRC Form 366A LICENSEE CONTACT FOR THIS LER 12 HAME John T~ St. Hartin - Director, Operating Experience TELEPHONE NUMBER (Include Area Code)

(315) 524-4446 C<NPLETE ONE LINE FOR EACH C<NPONENT FAILURE DESCRIBED IN THIS REPORT 13 REPORTABLE  %%)3%@i4 REPORTABLE CAUSE SYSTEH COHPOHEHT HANUFACTURER CAUSE SYSTEH COMPOHEHT HANUFACTURER TO NPRDS TO NPRDS jgc0pQWp:

SUPPLEMENTAL REPORT EXPECTED 14 EXPECTED MONTH DAY YEAR YES SUBMISSION (If yes, complete EXPECTED SUBHISSIOH DATE). X DATE (15)

ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten tines) (16)

The plant was at hot shutdown condition, with a reactor startup- in progress. At 0644 EST the reactor tripped on High Source Range Flux Level (>/= lE5 counts per second).

The underlying cause was determined to be a Control Room operator not adeguately focused on approaching the reactor trip setpoint. With two status lights burned out and a misleading PPCS alarm message, the operator was focused on Permissive P-6 setpoint instead of the reactor trip setpoint. (This event is NUREG-1220 (A) cause code.)

Corrective actions were to replace the status lights, correct the PPCS alarm message, and apprise the Control Room operators of the need to focus on reactor trip setpoints. Corrective action to preclude repetition is outlined in Section V (B).

NRC FORH 366 (5-92)

I NRC FORH 366A U.S IN)CLEAR REGULATORY COIIISSIQI APPROVED BY QQ NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIHATED BURDEN PER RESPONSE TO CONPLY llITH THIS IHFORNATIOH COLLECTIOH REQUEST: 50.0 HRS.

FORlIARD CONNEHTS REGARDIHG BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORHATION AND RECORDS HANAGEHENT BRANCH TEXT CONTINUATION (NHBB 7714), U.S. NUCLEAR REGULATORY COHHISSIOHg llASHIHGTON, DC 20555-0001 AND TO THE PAPERlSRK REDUCTIOH PROJECT (3140-0104), OFFICE OF HANAGENENT AND BUDGET MASHINGTON DC 20503.

FACILITY NAHE 1 DOCKET N(NBER 2 LER NIMBER 6 PAGE 3 SEOUEHTIAL REVISION YEAR R.E. Ginna Nuclear Power Plant 05000244'3 2 OF 7

-- 007 00 TEXT (If more space is required, use additional copies of HRC Form 366A) (17)

PRE-EVENT PLANT CONDITIONS The plant was stable in the hot shutdown condition, and the reactor was subcritical with a reactor startup in progress, using procedure 0-1.2 (Plant Startup From Hot Shutdown to Full Load).

II. DESCRIPTION OF EVENT A. DATES AND APPROXIMATE TIMES OF MAJOR OCCURRENCES:

o November 22, 1993, 0644 EST: Event date and time.

o November 22, 1993, 0644 EST: Discovery date and t'ime.

o November 22, 1993, 0644 EST: Control Room operators verify both reactor trip breakers open, and all control and shutdown rods inserted.

o November 22, 1993, 0650 EST: Plant stabilized at hot shutdown condition.

B. EVENT:

At approximately 0643 EST, the Control Room operators were conducting the final approach to criticality, in accordance with procedure 0-1.2. The operator performing the reactor startup was moving control rods out to establish a positive startup rate (SUR) prior to declaring the reactor critical. At this time, the two Nuclear Instrument System (NIS) Source Range (SR) instruments were indicating reactor power. at approximately 5E4 counts per second (CPS). The Control Room operator was anticipating that Permissive P-6 status lights would illuminate at this time, prior to exceeding the reactor trip setpoint of 1E5 CPS.

Permissive P-6 setpoint is generated from NIS Intermediate Range (IR) channels, when 1 of 2 channels is above 1E-10 amps. This is normally equivalent to approximately 1E4 CPS indication on the SR 'instruments. Permissive P-6 allows the Control Room, operator to manually block the High Source Range Flux Level reactor trip and de-energize the SR detectors.

NRC FORM 366A (5-92)

NRC FORH 366A U.S. NUCLEAR REGULATORY CNHIISSION APPROVED BY (NB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY WiTH THIS INFORHATION COLLECTIOH REQUEST: 50.0 HRS ~

FORWARD CONHENTS REGARDIHG BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AHD RECORDS HANAGEHEHT BRANCH TEXT CONTINUATION (HHBB 7714), U.S. NUCLEAR REGULATORY COHHISSIOH, WASHINGTON, DC 20555 0001 AHD TO THE PAPERWORK REDUCTION PROJECt (3150-0104), OFFICE OF HANAGEHENT AHD BUDGET WASHINGTON DC 20503.

FACILITY NAHE 1 DOCKET NNBER. 2 LER NNBER 6 PAGE 3 SEQUEHT IAL REVISION YEAR R.E. Ginna Nuclear Power Plant 05000244 93 007-- 00 3 OF 7 TEXT (If more space is required, use additionat copies of HRC Form 366A) (17)

Prior to the P-6 status lights illuminating, at approximately 0644 EST, the reactor tripped on High Source Range Flux Level

()/= 1E5 CPS). The Control Room operators performed the appropriate actions of Emergency Operating Procedure E-0 (Reactor Trip or Safety Injection), and verified that safety injection was not actuated or required. They then transitioned to Emergency Operating Procedure ES-0.1 (Reactor Trip Response).

The- plant was subsequently stabilized in hot shutdown, using procedure 0-2.1 (Normal Shutdown'to Hot Shutdown).

C~ INOPERABLE STRUCTURES g COMPONENTS / OR SYSTEMS THAT CONTRI BUTED TO THE EVENT:

o The light bulbs for the status lights that provide indication that reactor power is above Permissive P-6 were both burned out.

o Plant Process Computer System (PPCS) alarm message to indicate reactor power is above Permissive P-6 was misleading. With reactor power above the P-6 setpoint, the PPCS alarm message indicated that power was still below the setpoint.

D. OTHER SYSTEMS OR SECONDARY FUNCTIONS AFFECTED:

None E. METHOD OF DISCOVERY:

This event was immediately apparent due to Main Control Board Annunciator D-26 (Source Range Hi Flux Level Reactor Trip lE5 CPS) and other alarms and indications in the Control Room.

HRC FORH 366A (5 92)

I I

NRC FORH 366A U.S. INCLEAR REGULATORY CONI SSION APPROVED BY (NQ NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIHATED BURDEN PER RESPOHSE TO COHPLY MITH THIS INFORHATION COLLECTIOH REOUEST: 50.0 HRS.

FORMARD COHHEH'IS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE IHFORHATIOH AND RECORDS HANAGEHEHT BRANCH TEXT CONTINUATION (HNBB 7714), U.S. NUCLEAR REGULATORY,COHHISSION, MASHINGTOH, DC 20555-0001 AND TO THE PAPERNNK REDUCTION PROJECT (3'I40-0104), OFFICE OF HANAGEHENT AND BUDGET MASHINGTON DC 20503.

FACILITY lOWE 1 DOCKET NNIBER 2 LER NINBER 6 PAGE 3 SEOUENTIAL REVISION YEAR R.E. Ginna Nuclear Power Plant 05000244 93 007-- 00 4 OF 7 TEXT (If more space is required, use additional copies of HRC Form 366A) (17)

F. OPERATOR ACTION:

After the reactor trip, the Control Room operators performed the appropriate actions of Emergency Operating Procedures E-0 (Reactor Trip or Safety Injection) and ES-0.1 (Reactor Trip Response). The plant was stabilized at hot shutdown.

Subsequently, the Control Room operators notified higher supervision. The Nuclear Regulatory Commission was notified per 10CFR50.72, Non-Emergency, 4 Hour Notification at approximately 1022 EST.

G. SAFETY SYSTEM RESPONSES:

None III. CAUSE OF EVENT A. IMMEDIATE CAUSE:

The reactor trip was due to NIS SR high flux level above the SR reactor trip setpoint of 1E5 CPS.

B. INTERMEDIATE CAUSE:

The high flux level was caused by failure to block the SR reactor trip, after establishing a SUR of approximately 0.5 to 1 decades per minute (DPM) during the final approach to criticality, with power approaching the SR reactor trip setpoint.

NRC FORH 366A (5-92)

NRC FORM 366A U.S. NUCLEAR REGULATORY COHISSION APPROVED BY 0$ NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEH PER RESPOHSE TO COMPLY MITH THIS IHFORHATIOH COLLECT ION REQUEST: 50.0" HRS.

FORMARD COMMENTS REGARD IHG BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORHATION AND RECORDS MANAGEHEHT BRANCH TEXT CONTINUATION (HHBB 7714), U.S. NUCLEAR REGULATORY CDMHISSIOH ~

MASHINGTOH, DC 20555-0001 AHD TO THE PAPERNORK REDUCTION PROJECT (31i0-0104), OFF ICE OF MANAGEMENT AND BUDGET MASHINGTON DC 20503.

FACILITY NAME 1 DOCKET IRHIBER 2 LER MINBER 6 PAGE 3 SEQUENT I AL REVISION YEAR R.E. Ginna Nuclear Power Plant 05000244 93 007-- 00 5 OF 7 TEXT (If more space is required, use additional copies of HRC Form 366A) (17)

C. ROOT CAUSE:

The underlying cause of the failure to block the SR reactor trip with power increasing at a 0.5 to 1 DPM SUR, was cognitive personnel error by a Control Room operator. The Control Room operator was not adequately focused on approaching the SR.

reactor trip setpoint.

The Control Room operator was anticipating that the status lights indicating reactor power above Permissive P-6 setpoint would be illuminated, allowing block of the SR-reactor trip, prior to reaching the trip setpoint. His attention was focused on these status lights instead of on the approach to the reactor trip setpoint. The statusout.lights did not illuminate due to the light bulbs being burned The PPCS alarm message provided incorrect reinforcement that reactor power was still below the P-6 setpoint. The actions of the operator performing the reactor startup were not contrary to procedures established for this evolution. (This event is NUREG-1220 (A) cause code, Personnel Error.)

IV. ANALYSIS OF EVENT This event is reportable in accordance with 10 CFR 50.73, Licensee Event Report System, item (a) (2) (iv), which requires a report of, "any event or condition that resulted in manual or automatic actuation of any engineered safety feature (ESF) including the reactor protection system (RPS)". The reactor trip was an automatic actuation of the RPS.

An assessment was performed considering both the safety consequences and implications of this event with the following

~ results and conclusions:

There were no safety consequences or implications attributed to the reactor trip because:

o The two reactor trip breakers opened as required.

o All control and shutdown rods inserted as=- designed.

/

o The plant was stabilized at hot shutdown.

HRC FORM 366A (5-92)

NRC FORH 366A U.S. IR)CLEAR REGULATORY CQIIISS ION APPROVED BY QGI NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIHATED BURDEH PER RESPONSE TO COHPLY MITH THIS IHFORHATIOH COLLECTIOH REQUEST: 50.0 HRS.

FORllARD COHHEHTS REGARDIHG BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE IHFORHATIOH AND RECORDS HANAGEHEHT BRANCH TEXT CONTINUATION (HHBB 7714), U.S. NUCLEAR REGULATORY COHHISSIOH,

'WASHINGTON, DC 20555-0001 AHD TO THE PAPERIQRK REDUCTION PROJECT (3140-0104), OFFICE OF HAHAGEHEHT AHD BUDGET NASHIHGTOH DC 20503.

FACILITY NAHE 1 DOCKET NIMBER 2 LER NLSIBER 6 PAGE 3 SEQUENTIAL REVI SIOH R.E. Ginna Nuclear Power Plant '5000244 93 "

007-- 00 ' OF 7 TEXT (lf more space is required, use additional copies of HRC Form 366A) (Tl)

The reactor trip did not cause any reactor coolant system (RCS) transient, as the re'actor was not at the point of adding heat. All reactor protection circuitry actuated as designed to place the reactor in a tripped mode at hot shutdown.

Based on the above and a review of post trip data and past plant transients, it can be concluded that the plant operated as designed and that *there were no unreviewed safety questions and that the public's health and safety was assured at all times.

V. CORRECTIVE ACTION A. ACTION TAKEN TO RETURN AFFECTED SYSTEMS TO PRE-EVENT NORMAL STATUS:

o The light bulbs for the status lights that indicate reactor power is above P-6 were replaced, and a surveillance procedure was performed to verify their functionality.

o The PPCS alarm message for P-6 was corrected to ensure a clear understanding of the status of Permissive P-6.

0 Operations Management reevaluated their expectations for an appropriate approach to criticality at flux levels near the SR reactor trip setpoint, and communicated these revised expectations to the personnel on the Operating Shift scheduled to perform the subsequent reactor startup.

B. ACTION TAKEN OR PLANNED TO PREVENT RECURRENCE:

,0 Procedure 0-1.2 was revised to incorporate the revised management expectations. These included procedural guidance for (1) a conservative power level (below the SR reactor trip setpoint), where the power increase should be stopped if P-6 status lights have not to evaluate the status of P-6, illuminated, (2) a conservative SUR when the SR reactor trip setpoint is not defeated, (3) a formalized shift briefing conducted by the Shift Supervisor, prior to commencing a reactor startup.

NRC FORH 366A (5-92)

NRC FORH 366A U.S NICLEAR REGULATORY COHISSIOH APPROVED BY QHI NO. 3150-0104 (5-92) EXPIRES 5/31/95 EST IHATED BURDEN PER RESPONSE TO CONPLY illTH THIS INFORHAT ION COLLECT ION REQUEST: 50.0 HRS ~

FORllARD CONHENTS REGARD IHG BURDEN EST INATE TO LICENSEE EVENT REPORT (LER) THE INFORHAT ION AHD RECORDS HANAGEHEHT BRAHCH TEXT CONTINUATION (HHBB 7714), U.S. NUCLEAR REGULATORY CONHISSIOHg MASHIHGTOH, DC 20555-0001 AHD TO THE PAPERMORK N

REDUCTION PROJECT (3140-0104), OFF ICE OF HANAGENENT AND BUDGET NASHIHGTON DC 20503.

FACILITY l6WE 1 DOCKET Nl(BER 2 LER NNBER 6 PAGE 3 SEQUENTIAL REVISION YEAR R.E. Ginna Nuclear Power Plant 05000244 93 007-- 00 7 OF 7 TEXT (lf more space is required, use additional copies of HRC Form 366A) (17) 0 Personnel on the Operating Shift scheduled to perform the subsequent reactor startup were trained on the revisions to procedure 0-1.2 prior to commencing the startup.

0 A Human Performance Enhancement System (HPES) evaluation was performed to determine causal factors for this event. The

.results of the HPES evaluation were used to identify the root cause and appropriate corrective actions.

0 The two Control Room operators directly involved in this.

reactor trip were removed from shift until they had completed additional simulator training on reactor startups, and had been apprised of the revised management expectations contained in the revision to procedure 0-1.2.

0 All.licensed reactor operators, as part of normal training, will be trained on the revisions to procedure 0-1.2.

0 Appropriate lesson plans for the Licensed Operator Training programs will be revised to ensure management expectations contained in procedure 0-1.2 are continually reinforced during simulator training.

VI. ADDITIONAL INFORMATION A. FAILED COMPONENTS:

None B. PREVIOUS LERs ON SIMILAR EVENTS:

A similar LER event historical .search was conducted with the following results: No documentation of similar LER events with the same root cause at Ginna Nuclear Power Plant could be identified.

C. SPECIAL COMMENTS:

None HRC FORN 366A (5-92)

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