Information Notice 2010-06, Inadvertent Control Rod Withdrawal Event While Shutdown: Difference between revisions
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| issue date = 02/17/2010 | | issue date = 02/17/2010 | ||
| title = Inadvertent Control Rod Withdrawal Event While Shutdown | | title = Inadvertent Control Rod Withdrawal Event While Shutdown | ||
| author name = | | author name = Mcginty T | ||
| author affiliation = NRC/NRR/DPR | | author affiliation = NRC/NRR/DPR | ||
| addressee name = | | addressee name = | ||
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| page count = 6 | | page count = 6 | ||
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{{#Wiki_filter: | {{#Wiki_filter:UNITED STATES | ||
NUCLEAR REGULATORY COMMISSION | |||
NRC INFORMATION NOTICE 2010-06: INADVERTENT CONTROL ROD WITHDRAWAL EVENT WHILE SHUTDOWN | OFFICE OF NUCLEAR REACTOR REGULATION | ||
WASHINGTON, DC 20555-0001 February 17, 2010 | |||
NRC INFORMATION NOTICE 2010-06: INADVERTENT CONTROL ROD WITHDRAWAL | |||
EVENT WHILE SHUTDOWN | |||
==ADDRESSEES== | ==ADDRESSEES== | ||
All holders of operating licenses or construction permits for nuclear power reactors under the | All holders of operating licenses or construction permits for nuclear power reactors under the | ||
provisions of Title 10 of the | provisions of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Domestic Licensing | ||
of Production and Utilization Facilities, except those who have permanently ceased operations | |||
and have certified that fuel has been permanently removed from the reactor vessel. | |||
==PURPOSE== | ==PURPOSE== | ||
The U.S. Nuclear Regulatory Commission (NRC) is | The U.S. Nuclear Regulatory Commission (NRC) is issuing this information notice (IN) to alert | ||
addressees of recent operating experience involving an inadvertent control rod withdrawal event | |||
caused by a shutdown activity to isolate the water side of the control rod drive (CRD) hydraulic | |||
control units (HCUs) at a boiling-water reactor. The procedure utilized to perform this activity | |||
inadvertently replicated the normal control rod withdrawal hydraulic sequence for the last three | |||
HCUs isolated, resulting in three control rods being driven out of the core. The NRC expects | |||
that recipients will review the information for applicability to their facilities and consider actions, as appropriate, to avoid similar problems. Suggestions contained in this IN are not NRC | |||
requirements; therefore, no specific action or written response is required. | |||
==DESCRIPTION OF CIRCUMSTANCES== | ==DESCRIPTION OF CIRCUMSTANCES== | ||
On November 3, 2008, with Dresden Unit 3 in cold shutdown, three control rods inadvertently | On November 3, 2008, with Dresden Unit 3 in cold shutdown, three control rods inadvertently | ||
control rod position | withdrew to positions 06, 18, and 16, respectively (control rod position 00 indicates full-in and | ||
performed to isolate all 177 HCUs for CRD system maintenance. | control rod position 48 indicates full-out). The cause of the event was a deficient procedure | ||
performed to isolate all 177 HCUs for CRD system maintenance. The procedure specified | |||
sequentially isolating the HCUs with a CRD pump running which established the required | |||
hydraulic conditions for outward control rod motion (i.e., insert, unlatch, and withdraw). | hydraulic conditions for outward control rod motion (i.e., insert, unlatch, and withdraw). | ||
Line 45: | Line 66: | ||
The event occurred 10 hours after shutdown (approximately peak xenon concentration) at a | The event occurred 10 hours after shutdown (approximately peak xenon concentration) at a | ||
reactor coolant system (RCS) temperature of 168 °F. | reactor coolant system (RCS) temperature of 168 °F. During the event, the reactor remained | ||
shutdown with approximately 4.5 percent shutdown margin. However, an inadvertent criticality | |||
event could have occurred under different conditions given that the procedure did not place | |||
controls on RCS temperature or xenon concentration. | |||
the over-piston area was applied through the exhaust header (via the orificed check valve) through a designed reverse flow path in directional control valve 121 (which was shut), and then through the open withdraw valve (HCU 102). | The following describes how sequentially isolating the HCUs with a CRD pump running | ||
established the hydraulic conditions for outward control rod motion (i.e., insertion, unlatching, and withdrawal): | |||
Initial Plant Conditions. All 177 CRD HCU insert valves (HCU 101) and withdraw valves (HCU | |||
102) were open; all 177 CRD HCU directional control valves 120, 121, 122, and 123 were | |||
closed; and one CRD pump was operating applying pressure to each of the 177 unisolated HCU | |||
under-piston and over-piston areas (see Figure 1). Pressure to the under-piston area was | |||
applied through the cooling water header through the open insert valve (HCU 101). Pressure to | |||
the over-piston area was applied through the exhaust header (via the orificed check valve) | |||
through a designed reverse flow path in directional control valve 121 (which was shut), and then | |||
through the open withdraw valve (HCU 102). While the pressures to the under-piston and over- piston areas were roughly equal, a net inward force was applied because the under-piston has a | |||
larger surface area (see Figure 3a). | larger surface area (see Figure 3a). | ||
Figure 1 | Figure 1 Running 3B CRD pump and flow paths available to the unisolated HCUs | ||
Control Rod Insertion. | Control Rod Insertion. As shown in Figure 2, the CRD header pressure and proportional net | ||
decreased and since CRD header flow rate remained constant, system back pressure (i.e., | inward rod force was initially small because the flow paths to all 177 unisolated HCUs were | ||
available. Using procedural instructions, non-licensed operators began isolating the 177 HCUs | |||
one at a time. As each successive HCU was isolated, available CRD header flow paths | |||
decreased and since CRD header flow rate remained constant, system back pressure (i.e., | |||
CRD header differential pressure) increased resulting in an exponentially increasing the net | CRD header differential pressure) increased resulting in an exponentially increasing the net | ||
inward force on the remaining unisolated HCUs. | inward force on the remaining unisolated HCUs. After the 170th (NRC inspector determination) | ||
HCU was isolated, the net force to the under-piston area of the seven unisolated HCUs was | |||
sufficient to lift the CRD and insert the rod into the over-travel position (Figure 3b). [Note: NRC | |||
Inspection Report 05000249/2009009 discusses that the NRC inspector disagreed with the | |||
travel position.] Figure 2 The number of isolated HCUs versus CRD header pressure and the | licensees determination that only 5 control rods (rather than 7 control rods) inserted to an over- travel position.] Figure 2 The number of isolated HCUs versus CRD header pressure and the | ||
net force applied to the under-piston area of unisolated HCUs | net force applied to the under-piston area of unisolated HCUs | ||
Control Rod Unlatching. | Control Rod Unlatching. When the 174th HCU was isolated, CRD header differential pressure | ||
increased such that the control rods associated with the last three HCUs unlatched because of | |||
the force applied to the collet piston in the over-piston area was sufficient to compress the collet | the force applied to the collet piston in the over-piston area was sufficient to compress the collet | ||
Line 80: | Line 126: | ||
spring (Figure 3c). | spring (Figure 3c). | ||
Control Rod Withdrawal. | Control Rod Withdrawal. The withdrawal of the three unlatched control rods occurred due to the | ||
order the valves were closed to isolate the HCU. By procedure, each of the 177 HCUs was | |||
isolated by first closing its insert valve (HCU 101) and then closing its withdraw valve (HCU | |||
102). Closing the insert valve isolated the HCU under-piston area causing this area to | |||
depressurize through designed leakage flow paths. After the 175th HCUs insert valve was shut, the associated control rod was free to move out of the core because the rod was unlatched and | |||
a net force was applied to the over-piston area (Figure 3d). Outward control rod motion also | |||
occurred for the 176th and 177th HCUs for the same reason. Control rod motion continued until | |||
the non-licensed operator shut the associated HCU withdraw valve. The three control rods | |||
withdrew to the 06, 18, and 16 positions, respectively. | |||
Figure 3 Status of CRDs Operator Performance Issues. The licensee found that the main control room was not included | |||
in the pre-job brief, control room operators were unaware the activity was in progress or that a | |||
non-licensed operator was performing the HCU valve manipulations. | non-licensed operator was performing the HCU valve manipulations. This resulted in non- licensed operators manipulating mechanisms with the potential to affect reactivity without the | ||
knowledge and consent of a licensed operator at the controls, as required by 10 CFR 50.54(j). | knowledge and consent of a licensed operator at the controls, as required by 10 CFR 50.54(j). | ||
In addition, when the main control room received multiple unexpected control rod drift alarms | In addition, when the main control room received multiple unexpected control rod drift alarms | ||
than actual control rod movement. | and indications of rods being inserted to the over-travel position, control room operators first | ||
pursued whether the alarms may have been caused by known instrument maintenance rather | |||
than actual control rod movement. As a result, the first rod drift alarm in the control room | |||
preceded the first unplanned control rod motion by almost 18 minutes, and the last three control | preceded the first unplanned control rod motion by almost 18 minutes, and the last three control | ||
rods withdrew over the following 3 minutes. | rods withdrew over the following 3 minutes. When rod movement stopped after the non- licensed operator shut the last of the HCU withdraw valves, the main control room operators no | ||
longer had control over any of the 177 control rods. | longer had control over any of the 177 control rods. The control room operators did not notice | ||
that the CRD cooling water header pressure was off scale high, which covered in the alarm | that the CRD cooling water header pressure was off scale high, which covered in the alarm | ||
response procedure as potential cause for drifting rods. | response procedure as potential cause for drifting rods. Approximately 1 hour and 38 minutes | ||
after the first unplanned control rod movement, the operators completed the insertion of each of | after the first unplanned control rod movement, the operators completed the insertion of each of | ||
the three control rods by manually cycling the associated HCU insert valves. | |||
Root Cause Evaluation. The licensee determined that the root cause of this event was latent | |||
procedural deficiencies. The procedure did not contain any precautions, prerequisites, selection | |||
criteria, or limitations for the quantity of HCUs to be isolated with an operating CRD pump. The | |||
licensee had previously reviewed operating experience involving control rod withdrawal events | |||
at Japanese boiling-water reactors and had implemented procedural changes to prevent this | |||
* A | occurrence at the station. However, the licensee had not revised all of the affected procedures, including the one that was used during this event. | ||
* Operators not trusting their indications and promptly responding to a loss (or potential loss) of control rod control; | |||
* Non-licensed operators performing plant activities (HCU valve manipulations) that could affect reactivity, without the knowledge and consent of a licensed operator present at the | The licensee identified the following contributing factors for this event included: | ||
* An over reliance on a computer-based keyword search program system to identify | |||
applicable procedures when implementing a procedural change. | |||
* A shutdown mindset that did not emphasize that any maintenance on CRD HCUs | |||
should be considered for the potential effect on reactivity; | |||
* Operators not trusting their indications and promptly responding to a loss (or potential | |||
loss) of control rod control; | |||
* Non-licensed operators performing plant activities (HCU valve manipulations) that could | |||
affect reactivity, without the knowledge and consent of a licensed operator present at the | |||
controls. | controls. | ||
Specific corrective actions taken by the licensee included: | Specific corrective actions taken by the licensee included: identifying and updating all | ||
applicable procedures with key recommendations provided in the operating experience; | |||
specifying a minimum number of HCUs to be kept in service with a CRD pump operating while | |||
shutdown; monitoring CRD drive pressures, rod positions, and alarms during activities that | |||
could result in an inadvertent control rod movement; and ensuring that personnel who isolate | could result in an inadvertent control rod movement; and ensuring that personnel who isolate | ||
HCUs are aware that they can affect control rod system drive pressure | HCUs are aware that they can affect control rod system drive pressure and cause inadvertent | ||
and cause inadvertent | |||
control rod movement. | |||
Dresden Licensee Event Report 50-249/2008-003-00, dated December 31, 2008, and NRC Inspection Report 05000249/2009009, dated August 19, 2009. | Additional information is available in Dresden Licensee Event Report 50-249/2008-003-00, | ||
dated December 31, 2008, and NRC Inspection Report 05000249/2009009, dated August 19, 2009. This information can be found on the NRCs public website in the Agencywide | |||
Documents Access and Management System, under Accession Nos. ML090090372 and | Documents Access and Management System, under Accession Nos. ML090090372 and | ||
Line 155: | Line 227: | ||
==DISCUSSION== | ==DISCUSSION== | ||
This event illustrates the importance of licensees understanding that some field activities at boiling-water and pressurized-water reactors can significantly affect reactivity. | This event illustrates the importance of licensees understanding that some field activities at | ||
boiling-water and pressurized-water reactors can significantly affect reactivity. The regulation at | |||
10 CFR 50.54(j) requires that the operation of apparatus and mechanisms that may affect the | |||
reactivity of a reactor shall be manipulated only with the knowledge and consent of a licensed | reactivity of a reactor shall be manipulated only with the knowledge and consent of a licensed | ||
operator present at the controls. | operator present at the controls. In this case, the action of non-licensed operators using a | ||
deficient procedure to manually isolate the HCUs in the field led to multiple control rods moving | |||
out of the core without the prior knowledge or consent of the licensed control room operators. | |||
Moreover, the licensed operators failure to believe the control room indications unnecessarily | |||
delayed their diagnosis of, and response to, the event. Under a different set of initial conditions, this event could have resulted in an inadvertent criticality. | |||
==CONTACT== | ==CONTACT== | ||
This IN requires no specific action or written response. | This IN requires no specific action or written response. Please direct any questions about this | ||
matter to the technical contacts listed below or the appropriate Office of Nuclear Reactor | matter to the technical contacts listed below or the appropriate Office of Nuclear Reactor | ||
Line 170: | Line 252: | ||
Regulation project manager. | Regulation project manager. | ||
/RA/ | /RA/ | ||
Timothy J. McGinty, Director | Timothy J. McGinty, Director | ||
Division of Policy and Rulemaking | |||
Office of Nuclear Reactor Regulation | |||
Technical Contacts: Mark Ring, RIII Jamie Benjamin, RIII | Technical Contacts: Mark Ring, RIII Jamie Benjamin, RIII | ||
630/829-9703 630/829-9753 | 630/829-9703 630/829-9753 E-mail: Mark.Ring@nrc.gov E-mail: Jamie.Benjamin@nrc.gov | ||
Jamie.Benjamin@nrc.gov | |||
Carey Brown, RIII | Carey Brown, RIII | ||
630/829-9605 E-mail: | 630/829-9605 E-mail: Carey.Brown@nrc.gov | ||
Note: NRC generic communications may be found on the NRC public Web site, http://www.nrc.gov, under Electronic Reading Room/Document Collections. August 19, 2009. This information can be found on the NRCs public website in the Agencywide | |||
Documents Access and Management System, under Accession Nos. ML090090372 and | |||
ML092320164, respectively. | ML092320164, respectively. | ||
==DISCUSSION== | ==DISCUSSION== | ||
This event illustrates the importance of licensees understanding that some field activities at boiling-water and pressurized-water reactors can significantly affect reactivity. | This event illustrates the importance of licensees understanding that some field activities at | ||
boiling-water and pressurized-water reactors can significantly affect reactivity. The regulation at | |||
10 CFR 50.54(j) requires that the operation of apparatus and mechanisms that may affect the | |||
reactivity of a reactor shall be manipulated only with the knowledge and consent of a licensed | reactivity of a reactor shall be manipulated only with the knowledge and consent of a licensed | ||
operator present at the controls. | operator present at the controls. In this case, the action of non-licensed operators using a | ||
deficient procedure to manually isolate the HCUs in the field led to multiple control rods moving | |||
out of the core without the prior knowledge or consent of the licensed control room operators. | |||
Moreover, the licensed operators failure to believe the control room indications unnecessarily | |||
delayed their diagnosis of, and response to, the event. Under a different set of initial conditions, this event could have resulted in an inadvertent criticality. | |||
==CONTACT== | ==CONTACT== | ||
This IN requires no specific action or written response. | This IN requires no specific action or written response. Please direct any questions about this | ||
matter to the technical contacts listed below or the appropriate Office of Nuclear Reactor | matter to the technical contacts listed below or the appropriate Office of Nuclear Reactor | ||
Line 204: | Line 299: | ||
Regulation project manager. | Regulation project manager. | ||
/RA/ | /RA/ | ||
Timothy J. McGinty, Director | Timothy J. McGinty, Director | ||
Division of Policy and Rulemaking | |||
Office of Nuclear Reactor Regulation | |||
Technical Contacts: Mark Ring, RIII Jamie Benjamin, RIII | Technical Contacts: Mark Ring, RIII Jamie Benjamin, RIII | ||
630/829-9703 630/829-9753 | 630/829-9703 630/829-9753 E-mail: Mark.Ring@nrc.gov E-mail: Jamie.Benjamin@nrc.gov | ||
Jamie.Benjamin@nrc.gov | |||
Carey Brown, RIII | Carey Brown, RIII | ||
630/829-9605 E-mail: | 630/829-9605 E-mail: Carey.Brown@nrc.gov | ||
Note: NRC generic communications may be found on the NRC public Web site, http://www.nrc.gov, under Electronic Reading Room/Document Collections. | |||
ADAMS Accession Number: ML092190302 TAC ME0707 OFFICE RIII TECH EDITOR BC:RIII:DRP BC:IOLB:DIRS D:DIRS | |||
NAME JBenjamin KAzariah-Kribbs MRing JMunro FBrown | |||
BC:PGCB:NRR | DATE 9/1/09 e-mail 8/21/09 e-mail 9/1/09 e-mail 9/2/09 9/2/09 OFFICE LA:PGCB:NRR PM:PGCB:NRR BC:PGCB:NRR D:DPR:NRR | ||
NAME CHawes DBeaulieu MMurphy TMcGinty | |||
OFFICE 2/16/10 9/2/09 2/16/10 2/17/10 | |||
OFFICIAL RECORD COPY}} | |||
{{Information notice-Nav}} | {{Information notice-Nav}} |
Latest revision as of 04:25, 14 November 2019
ML092190302 | |
Person / Time | |
---|---|
Issue date: | 02/17/2010 |
From: | Mcginty T Division of Policy and Rulemaking |
To: | |
David Beaulieu | |
References | |
IN-10-006 | |
Download: ML092190302 (6) | |
UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR REACTOR REGULATION
WASHINGTON, DC 20555-0001 February 17, 2010
NRC INFORMATION NOTICE 2010-06: INADVERTENT CONTROL ROD WITHDRAWAL
EVENT WHILE SHUTDOWN
ADDRESSEES
All holders of operating licenses or construction permits for nuclear power reactors under the
provisions of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Domestic Licensing
of Production and Utilization Facilities, except those who have permanently ceased operations
and have certified that fuel has been permanently removed from the reactor vessel.
PURPOSE
The U.S. Nuclear Regulatory Commission (NRC) is issuing this information notice (IN) to alert
addressees of recent operating experience involving an inadvertent control rod withdrawal event
caused by a shutdown activity to isolate the water side of the control rod drive (CRD) hydraulic
control units (HCUs) at a boiling-water reactor. The procedure utilized to perform this activity
inadvertently replicated the normal control rod withdrawal hydraulic sequence for the last three
HCUs isolated, resulting in three control rods being driven out of the core. The NRC expects
that recipients will review the information for applicability to their facilities and consider actions, as appropriate, to avoid similar problems. Suggestions contained in this IN are not NRC
requirements; therefore, no specific action or written response is required.
DESCRIPTION OF CIRCUMSTANCES
On November 3, 2008, with Dresden Unit 3 in cold shutdown, three control rods inadvertently
withdrew to positions 06, 18, and 16, respectively (control rod position 00 indicates full-in and
control rod position 48 indicates full-out). The cause of the event was a deficient procedure
performed to isolate all 177 HCUs for CRD system maintenance. The procedure specified
sequentially isolating the HCUs with a CRD pump running which established the required
hydraulic conditions for outward control rod motion (i.e., insert, unlatch, and withdraw).
The event occurred 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> after shutdown (approximately peak xenon concentration) at a
reactor coolant system (RCS) temperature of 168 °F. During the event, the reactor remained
shutdown with approximately 4.5 percent shutdown margin. However, an inadvertent criticality
event could have occurred under different conditions given that the procedure did not place
controls on RCS temperature or xenon concentration.
The following describes how sequentially isolating the HCUs with a CRD pump running
established the hydraulic conditions for outward control rod motion (i.e., insertion, unlatching, and withdrawal):
Initial Plant Conditions. All 177 CRD HCU insert valves (HCU 101) and withdraw valves (HCU
102) were open; all 177 CRD HCU directional control valves 120, 121, 122, and 123 were
closed; and one CRD pump was operating applying pressure to each of the 177 unisolated HCU
under-piston and over-piston areas (see Figure 1). Pressure to the under-piston area was
applied through the cooling water header through the open insert valve (HCU 101). Pressure to
the over-piston area was applied through the exhaust header (via the orificed check valve)
through a designed reverse flow path in directional control valve 121 (which was shut), and then
through the open withdraw valve (HCU 102). While the pressures to the under-piston and over- piston areas were roughly equal, a net inward force was applied because the under-piston has a
larger surface area (see Figure 3a).
Figure 1 Running 3B CRD pump and flow paths available to the unisolated HCUs
Control Rod Insertion. As shown in Figure 2, the CRD header pressure and proportional net
inward rod force was initially small because the flow paths to all 177 unisolated HCUs were
available. Using procedural instructions, non-licensed operators began isolating the 177 HCUs
one at a time. As each successive HCU was isolated, available CRD header flow paths
decreased and since CRD header flow rate remained constant, system back pressure (i.e.,
CRD header differential pressure) increased resulting in an exponentially increasing the net
inward force on the remaining unisolated HCUs. After the 170th (NRC inspector determination)
HCU was isolated, the net force to the under-piston area of the seven unisolated HCUs was
sufficient to lift the CRD and insert the rod into the over-travel position (Figure 3b). [Note: NRC
Inspection Report 05000249/2009009 discusses that the NRC inspector disagreed with the
licensees determination that only 5 control rods (rather than 7 control rods) inserted to an over- travel position.] Figure 2 The number of isolated HCUs versus CRD header pressure and the
net force applied to the under-piston area of unisolated HCUs
Control Rod Unlatching. When the 174th HCU was isolated, CRD header differential pressure
increased such that the control rods associated with the last three HCUs unlatched because of
the force applied to the collet piston in the over-piston area was sufficient to compress the collet
spring (Figure 3c).
Control Rod Withdrawal. The withdrawal of the three unlatched control rods occurred due to the
order the valves were closed to isolate the HCU. By procedure, each of the 177 HCUs was
isolated by first closing its insert valve (HCU 101) and then closing its withdraw valve (HCU
102). Closing the insert valve isolated the HCU under-piston area causing this area to
depressurize through designed leakage flow paths. After the 175th HCUs insert valve was shut, the associated control rod was free to move out of the core because the rod was unlatched and
a net force was applied to the over-piston area (Figure 3d). Outward control rod motion also
occurred for the 176th and 177th HCUs for the same reason. Control rod motion continued until
the non-licensed operator shut the associated HCU withdraw valve. The three control rods
withdrew to the 06, 18, and 16 positions, respectively.
Figure 3 Status of CRDs Operator Performance Issues. The licensee found that the main control room was not included
in the pre-job brief, control room operators were unaware the activity was in progress or that a
non-licensed operator was performing the HCU valve manipulations. This resulted in non- licensed operators manipulating mechanisms with the potential to affect reactivity without the
knowledge and consent of a licensed operator at the controls, as required by 10 CFR 50.54(j).
In addition, when the main control room received multiple unexpected control rod drift alarms
and indications of rods being inserted to the over-travel position, control room operators first
pursued whether the alarms may have been caused by known instrument maintenance rather
than actual control rod movement. As a result, the first rod drift alarm in the control room
preceded the first unplanned control rod motion by almost 18 minutes, and the last three control
rods withdrew over the following 3 minutes. When rod movement stopped after the non- licensed operator shut the last of the HCU withdraw valves, the main control room operators no
longer had control over any of the 177 control rods. The control room operators did not notice
that the CRD cooling water header pressure was off scale high, which covered in the alarm
response procedure as potential cause for drifting rods. Approximately 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> and 38 minutes
after the first unplanned control rod movement, the operators completed the insertion of each of
the three control rods by manually cycling the associated HCU insert valves.
Root Cause Evaluation. The licensee determined that the root cause of this event was latent
procedural deficiencies. The procedure did not contain any precautions, prerequisites, selection
criteria, or limitations for the quantity of HCUs to be isolated with an operating CRD pump. The
licensee had previously reviewed operating experience involving control rod withdrawal events
at Japanese boiling-water reactors and had implemented procedural changes to prevent this
occurrence at the station. However, the licensee had not revised all of the affected procedures, including the one that was used during this event.
The licensee identified the following contributing factors for this event included:
- An over reliance on a computer-based keyword search program system to identify
applicable procedures when implementing a procedural change.
should be considered for the potential effect on reactivity;
- Operators not trusting their indications and promptly responding to a loss (or potential
loss) of control rod control;
- Non-licensed operators performing plant activities (HCU valve manipulations) that could
affect reactivity, without the knowledge and consent of a licensed operator present at the
controls.
Specific corrective actions taken by the licensee included: identifying and updating all
applicable procedures with key recommendations provided in the operating experience;
specifying a minimum number of HCUs to be kept in service with a CRD pump operating while
shutdown; monitoring CRD drive pressures, rod positions, and alarms during activities that
could result in an inadvertent control rod movement; and ensuring that personnel who isolate
HCUs are aware that they can affect control rod system drive pressure and cause inadvertent
control rod movement.
Additional information is available in Dresden Licensee Event Report 50-249/2008-003-00,
dated December 31, 2008, and NRC Inspection Report 05000249/2009009, dated August 19, 2009. This information can be found on the NRCs public website in the Agencywide
Documents Access and Management System, under Accession Nos. ML090090372 and
ML092320164, respectively.
DISCUSSION
This event illustrates the importance of licensees understanding that some field activities at
boiling-water and pressurized-water reactors can significantly affect reactivity. The regulation at
10 CFR 50.54(j) requires that the operation of apparatus and mechanisms that may affect the
reactivity of a reactor shall be manipulated only with the knowledge and consent of a licensed
operator present at the controls. In this case, the action of non-licensed operators using a
deficient procedure to manually isolate the HCUs in the field led to multiple control rods moving
out of the core without the prior knowledge or consent of the licensed control room operators.
Moreover, the licensed operators failure to believe the control room indications unnecessarily
delayed their diagnosis of, and response to, the event. Under a different set of initial conditions, this event could have resulted in an inadvertent criticality.
CONTACT
This IN requires no specific action or written response. Please direct any questions about this
matter to the technical contacts listed below or the appropriate Office of Nuclear Reactor
Regulation project manager.
/RA/
Timothy J. McGinty, Director
Division of Policy and Rulemaking
Office of Nuclear Reactor Regulation
Technical Contacts: Mark Ring, RIII Jamie Benjamin, RIII
630/829-9703 630/829-9753 E-mail: Mark.Ring@nrc.gov E-mail: Jamie.Benjamin@nrc.gov
Carey Brown, RIII
630/829-9605 E-mail: Carey.Brown@nrc.gov
Note: NRC generic communications may be found on the NRC public Web site, http://www.nrc.gov, under Electronic Reading Room/Document Collections. August 19, 2009. This information can be found on the NRCs public website in the Agencywide
Documents Access and Management System, under Accession Nos. ML090090372 and
ML092320164, respectively.
DISCUSSION
This event illustrates the importance of licensees understanding that some field activities at
boiling-water and pressurized-water reactors can significantly affect reactivity. The regulation at
10 CFR 50.54(j) requires that the operation of apparatus and mechanisms that may affect the
reactivity of a reactor shall be manipulated only with the knowledge and consent of a licensed
operator present at the controls. In this case, the action of non-licensed operators using a
deficient procedure to manually isolate the HCUs in the field led to multiple control rods moving
out of the core without the prior knowledge or consent of the licensed control room operators.
Moreover, the licensed operators failure to believe the control room indications unnecessarily
delayed their diagnosis of, and response to, the event. Under a different set of initial conditions, this event could have resulted in an inadvertent criticality.
CONTACT
This IN requires no specific action or written response. Please direct any questions about this
matter to the technical contacts listed below or the appropriate Office of Nuclear Reactor
Regulation project manager.
/RA/
Timothy J. McGinty, Director
Division of Policy and Rulemaking
Office of Nuclear Reactor Regulation
Technical Contacts: Mark Ring, RIII Jamie Benjamin, RIII
630/829-9703 630/829-9753 E-mail: Mark.Ring@nrc.gov E-mail: Jamie.Benjamin@nrc.gov
Carey Brown, RIII
630/829-9605 E-mail: Carey.Brown@nrc.gov
Note: NRC generic communications may be found on the NRC public Web site, http://www.nrc.gov, under Electronic Reading Room/Document Collections.
ADAMS Accession Number: ML092190302 TAC ME0707 OFFICE RIII TECH EDITOR BC:RIII:DRP BC:IOLB:DIRS D:DIRS
NAME JBenjamin KAzariah-Kribbs MRing JMunro FBrown
DATE 9/1/09 e-mail 8/21/09 e-mail 9/1/09 e-mail 9/2/09 9/2/09 OFFICE LA:PGCB:NRR PM:PGCB:NRR BC:PGCB:NRR D:DPR:NRR
NAME CHawes DBeaulieu MMurphy TMcGinty
OFFICE 2/16/10 9/2/09 2/16/10 2/17/10
OFFICIAL RECORD COPY