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NRCFORH366A(5-92)U.S.IR)CLEARREGULATORYCQIIISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYQGINO.3150-0104EXPIRES5/31/95ESTIHATEDBURDEHPERRESPONSETOCOHPLYMITHTHISIHFORHATIOHCOLLECTIOHREQUEST:50.0HRS.FORllARDCOHHEHTSREGARDIHGBURDENESTIHATETOTHEIHFORHATIOHANDRECORDSHANAGEHEHTBRANCH(HHBB7714),U.S.NUCLEARREGULATORYCOHHISSIOH,'WASHINGTON,DC20555-0001AHDTOTHEPAPERIQRKREDUCTIONPROJECT(3140-0104),OFFICEOFHAHAGEHEHTAHDBUDGETNASHIHGTOHDC20503.FACILITYNAHE1DOCKETNIMBER2LERNLSIBER6SEQUENTIALREVISIOHPAGE3R.E.GinnaNuclearPowerPlant'500024493"-007--00'OF7TEXT(lfmorespaceisrequired,useadditionalcopiesofHRCForm366A)(Tl)Thereactortripdidnotcauseanyreactorcoolantsystem(RCS)transient,asthere'actorwasnotatthepointofaddingheat.Allreactorprotectioncircuitryactuatedasdesignedtoplacethereactorinatrippedmodeathotshutdown.Basedontheaboveandareviewofposttripdataandpastplanttransients,itcanbeconcludedthattheplantoperatedasdesignedandthat*therewerenounreviewedsafetyquestionsandthatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVEACTIONA.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENTNORMALSTATUS:oThelightbulbsforthestatuslightsthatindicatereactorpowerisaboveP-6werereplaced,andasurveillanceprocedurewasperformedtoverifytheirfunctionality.oThePPCSalarmmessageforP-6wascorrectedtoensureaclearunderstandingofthestatusofPermissiveP-6.0OperationsManagementreevaluatedtheirexpectationsforanappropriateapproachtocriticalityatfluxlevelsneartheSRreactortripsetpoint,andcommunicatedtheserevisedexpectationstothepersonnelontheOperatingShiftscheduledtoperformthesubsequentreactorstartup.B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:,0Procedure0-1.2wasrevisedtoincorporatetherevisedmanagementexpectations.Theseincludedproceduralguidancefor(1)aconservativepowerlevel(belowtheSRreactortripsetpoint),wherethepowerincreaseshouldbestoppedtoevaluatethestatusofP-6,ifP-6statuslightshavenotilluminated,(2)aconservativeSURwhentheSRreactortripsetpointisnotdefeated,(3)aformalizedshiftbriefingconductedbytheShiftSupervisor,priortocommencingareactorstartup.NRCFORH366A(5-92)  
NRCFORH366A(5-92)U.S.IR)CLEARREGULATORYCQIIISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYQGINO.3150-0104EXPIRES5/31/95ESTIHATEDBURDEHPERRESPONSETOCOHPLYMITHTHISIHFORHATIOHCOLLECTIOHREQUEST:50.0HRS.FORllARDCOHHEHTSREGARDIHGBURDENESTIHATETOTHEIHFORHATIOHANDRECORDSHANAGEHEHTBRANCH(HHBB7714),U.S.NUCLEARREGULATORYCOHHISSIOH,'WASHINGTON,DC20555-0001AHDTOTHEPAPERIQRKREDUCTIONPROJECT(3140-0104),OFFICEOFHAHAGEHEHTAHDBUDGETNASHIHGTOHDC20503.FACILITYNAHE1DOCKETNIMBER2LERNLSIBER6SEQUENTIALREVISIOHPAGE3R.E.GinnaNuclearPowerPlant'500024493"-007--00'OF7TEXT(lfmorespaceisrequired,useadditionalcopiesofHRCForm366A)(Tl)Thereactortripdidnotcauseanyreactorcoolantsystem(RCS)transient,asthere'actorwasnotatthepointofaddingheat.Allreactorprotectioncircuitryactuatedasdesignedtoplacethereactorinatrippedmodeathotshutdown.Basedontheaboveandareviewofposttripdataandpastplanttransients,itcanbeconcludedthattheplantoperatedasdesignedandthat*therewerenounreviewedsafetyquestionsandthatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVEACTIONA.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENTNORMALSTATUS:oThelightbulbsforthestatuslightsthatindicatereactorpowerisaboveP-6werereplaced,andasurveillanceprocedurewasperformedtoverifytheirfunctionality.oThePPCSalarmmessageforP-6wascorrectedtoensureaclearunderstandingofthestatusofPermissiveP-6.0OperationsManagementreevaluatedtheirexpectationsforanappropriateapproachtocriticalityatfluxlevelsneartheSRreactortripsetpoint,andcommunicatedtheserevisedexpectationstothepersonnelontheOperatingShiftscheduledtoperformthesubsequentreactorstartup.B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:,0Procedure0-1.2wasrevisedtoincorporatetherevisedmanagementexpectations.Theseincludedproceduralguidancefor(1)aconservativepowerlevel(belowtheSRreactortripsetpoint),wherethepowerincreaseshouldbestoppedtoevaluatethestatusofP-6,ifP-6statuslightshavenotilluminated,(2)aconservativeSURwhentheSRreactortripsetpointisnotdefeated,(3)aformalizedshiftbriefingconductedbytheShiftSupervisor,priortocommencingareactorstartup.NRCFORH366A(5-92)  


NRCFORH366A(5-92)U.SNICLEARREGULATORYCOHISSIOHLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONNAPPROVEDBYQHINO.3150-0104EXPIRES5/31/95ESTIHATEDBURDENPERRESPONSETOCONPLYillTHTHISINFORHATIONCOLLECTIONREQUEST:50.0HRS~FORllARDCONHENTSREGARDIHGBURDENESTINATETOTHEINFORHATIONAHDRECORDSHANAGEHEHTBRAHCH(HHBB7714),U.S.NUCLEARREGULATORYCONHISSIOHgMASHIHGTOH,DC20555-0001AHDTOTHEPAPERMORKREDUCTIONPROJECT(3140-0104),OFFICEOFHANAGENENTANDBUDGETNASHIHGTONDC20503.FACILITYl6WE1R.E.GinnaNuclearPowerPlantDOCKETNl(BER20500024493-007--00LERNNBER6YEARSEQUENTIALREVISIONPAGE37OF7TEXT(lfmorespace00isrequired,useadditionalcopiesofHRCForm366A)(17)PersonnelontheOperatingShiftscheduledtoperformthesubsequentreactorstartupweretrainedontherevisionstoprocedure0-1.2priortocommencingthestartup.AHumanPerformanceEnhancementSystem(HPES)evaluationwasperformedtodeterminecausalfactorsforthisevent.The.resultsoftheHPESevaluationwereusedtoidentifytherootcauseandappropriatecorrectiveactions.0ThetwoControlRoomoperatorsdirectlyinvolvedinthis.reactortripwereremovedfromshiftuntiltheyhadcompletedadditionalsimulatortrainingonreactorstartups,andhadbeenapprisedoftherevisedmanagementexpectationscontainedintherevisiontoprocedure0-1.2.00All.licensedreactoroperators,aspartofnormaltraining,willbetrainedontherevisionstoprocedure0-1.2.AppropriatelessonplansfortheLicensedOperatorTrainingprogramswillberevisedtoensuremanagementexpectationscontainedinprocedure0-1.2arecontinuallyreinforcedduringsimulatortraining.VI.ADDITIONALINFORMATIONA.FAILEDCOMPONENTS:NoneB.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistorical.searchwasconductedwiththefollowingresults:NodocumentationofsimilarLEReventswiththesamerootcauseatGinnaNuclearPowerPlantcouldbeidentified.C.SPECIALCOMMENTS:NoneHRCFORN366A(5-92) 7  
NRCFORH366A(5-92)U.SNICLEARREGULATORYCOHISSIOHLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONNAPPROVEDBYQHINO.3150-0104EXPIRES5/31/95ESTIHATEDBURDENPERRESPONSETOCONPLYillTHTHISINFORHATIONCOLLECTIONREQUEST:50.0HRS~FORllARDCONHENTSREGARDIHGBURDENESTINATETOTHEINFORHATIONAHDRECORDSHANAGEHEHTBRAHCH(HHBB7714),U.S.NUCLEARREGULATORYCONHISSIOHgMASHIHGTOH,DC20555-0001AHDTOTHEPAPERMORKREDUCTIONPROJECT(3140-0104),OFFICEOFHANAGENENTANDBUDGETNASHIHGTONDC20503.FACILITYl6WE1R.E.GinnaNuclearPowerPlantDOCKETNl(BER20500024493-007--00LERNNBER6YEARSEQUENTIALREVISIONPAGE37OF7TEXT(lfmorespace00isrequired,useadditionalcopiesofHRCForm366A)(17)PersonnelontheOperatingShiftscheduledtoperformthesubsequentreactorstartupweretrainedontherevisionstoprocedure0-1.2priortocommencingthestartup.AHumanPerformanceEnhancementSystem(HPES)evaluationwasperformedtodeterminecausalfactorsforthisevent.The.resultsoftheHPESevaluationwereusedtoidentifytherootcauseandappropriatecorrectiveactions.0ThetwoControlRoomoperatorsdirectlyinvolvedinthis.reactortripwereremovedfromshiftuntiltheyhadcompletedadditionalsimulatortrainingonreactorstartups,andhadbeenapprisedoftherevisedmanagementexpectationscontainedintherevisiontoprocedure0-1.2.00All.licensedreactoroperators,aspartofnormaltraining,willbetrainedontherevisionstoprocedure0-1.2.AppropriatelessonplansfortheLicensedOperatorTrainingprogramswillberevisedtoensuremanagementexpectationscontainedinprocedure0-1.2arecontinuallyreinforcedduringsimulatortraining.VI.ADDITIONALINFORMATIONA.FAILEDCOMPONENTS:NoneB.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistorical.searchwasconductedwiththefollowingresults:NodocumentationofsimilarLEReventswiththesamerootcauseatGinnaNuclearPowerPlantcouldbeidentified.C.SPECIALCOMMENTS:NoneHRCFORN366A(5-92) 7}}
}}

Revision as of 12:32, 18 May 2018

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 Constellation icon.png
Issue date: 12/22/1993
From: MARTIN J T, MECREDY R C
ROCHESTER GAS & ELECTRIC CORP.
To: JOHNSON A R
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

ACCELERATEDDISTRIBUTIONDEMONSTRATIONSYSTEMREGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ACCESSIONNBR:9401110017DOC.DATE:93/12/22NOTARIZED:NOFACIL:50-244RobertEmmetGinnaNuclearPlant,Unit1,RochesterGAUTH.'AMEAUTHORAFFILIATIONMARTIN,J.T.RochesterGas&ElectricCorp.MECREDY,R.C.,RochesterGas&ElectricCorp.RECIP.NAMERECIPIENTAFFILIATIONDOCKET05000244R'OHNSON,A.R.ProjectDirectorateI-3

SUBJECT:

LER93-007-00:on931122,RToccurredduetohighsourcerangefluxlevelduringreactorstartup.CausedbyfailureofpersonnelfocusingonRTsetpoint.Replacedstatuslights&correctedPPCSalarmmessage.W/931222ltr.DISTRIBUTIONCODE:IE22TCOPIESRECEIVED:LTRENCLSIZE:TITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.ID',$RECIPIENTIDCODE/NAMEPD1-3LAJOHNSON,ACOPIESLTTRENCL1111RECIPIENTIDCODE/NAMEPD1-3PDCOPIESLTTRENCL11NOTES:LicenseExpdateinaccordancewith10CFR2,2.109(9/19/72).A05000244DD,INTERNAL:AEOD/DOAAEOD/ROAB/DSPNRR/DE/EMEBNRR/DRCH/HHFB,NRR/DRCH/HOLBNRR/DRSS/PRPBNRR/DSSA/SRXBRES/DSIR/EIBEXTERNALEG&GBRYCEgJ~HNRCPDRNSICPOORE,W.112211111122111122.1111AEOD/DSP/TPABNRR/DE/EELBNRR/DORS/OEABNRR/DRCH/HICBNRR/DRIL/RPEBQB~RDSSQ/DPLBLSTLOBBYWARDNSICMURPHYgG~ANUDOCSFULLTXT1111111111111111111111DNOTETOALL"RIDS"RECIPIENTS:PLEASEHELPUSTOREDUCElVASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOiblPI-37(EXT.20079)TOELIiVIINATEYOURNAMEFROMDISTRIBUTIONLISTSFORDOCUMENTSYOUDON'TNEED!DDS-FULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR28ENCL28

ROCHESTERGASANDELECTRICCORPORATIONeR6BERTC,MEGREOYVicePresiden<CinnaNuclearProduriionrionK.ssssr89EASTAVENUE,ROCHESTERN.Y.14649-0001TELEPHONEAsrEACODE7165462700December22,1993U.S.NuclearRegulatoryCommissionAttn:AllenR.JohnsonProjectDirectorateI-3DocumentControlDeskWashington,DC20555

Subject:

LER93-007,HighSourceRangeFluxLevelDuringReactorStartupCausesaReactorTripR.E.GinnaNuclearPowerPlantDocketNo.50-244item(a2ivInaccordancewith10CFR50.73LicenseeEvtRt)()(zv),who.chrequiresareportof,"anyeventor~IeneporSystem,conditionthatresultedinamanualorautomaticctt'aeyfeature(ESF),includingthereactorprotectionsystem(RPS)",theattachedLicenseeEventReportLER93-007herebysubmitted.071sThxseventhasinnowayaffectedthepublic'shealthandsafety.Verytrulyyours,RobertC.MecredyXCU.S.NuclearRegulatoryCommissionRegionI475AllendaleRoadKingofPrussia,PA19406GinnaUSNRCSeniorResidentInspector060053.9401>~OOX793>~~>PDRADQCK050002POR

NRCFORH366(5-92)U.S.II)CLEARREGULATORYC<NNIISSIONAPPROVEDBYQGINO.3150-0104EXPIRES5/31/95LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/charactersforeachblock)ESTIMATEDBURDENPERRESPONSETOCOMPLYlllTHTHISINFORMATIONCOLLECTIONREQUEST:50.0HRS.FORHARDCOMMENTSREGARDIHGBURDENESTIMATETOTHEIHFORHATIOHANDRECORDSMANAGEHENTBRANCH(HNBB7714),U.S.NUCLEARREGULATORYCOMHISSIOH,NASHINGTOH,DC20555-0001ANDTOTHEPAPERUORKREDUCTIONPROJECT(31/0-0104),OFFICEOFMAHAGEHENTANDBUDGETNASHINGTONDC20503-FAclLITYlQ%(1)R.E~GinnaNuclearPowerPlantDOCKETNQIBER(2)=05000244PAGE(3)1OF7TITLE(4)HighSourceRangeFluxLevelDuringReactorStartupCausesaReactorTripEVENTDATE5LERINNBER6REPORTDATE7OTHERFACILITIESINVOLVED8MONTHDAY1122YEAR93YEAR93SEQUENTIALHUHBER--007--REVISIONNUMBER00MOHTH12,DAY22FACILITYNAHEYEARFACILITYHAMEDOCKETNUMBERDOCKETNUMBERSTRAYINGINXIE,(9)POUERLEVEL(10)N000THISREPORTISSUBMITTEDPURSUANT20.402(b)20.405(a)(1)(i)20.405(a)(1)(ii)20.405(a)(1)(iii)20.405<a)(1)(iv)20.405(a)(1)(v)20.405(c)50.36(c)(1)50.36(c)(2)50.73(a)(2)(i)50.73(a)(2)(ii)50.73(a)(2)(iii)50.73(a)(2)(iv)50.73(a)(2)(v)50.73(a)(2)(vii)50.73(a)(2)(viii)(A)50.73(a)(2)(viii)(B)50.73(a)<2)(x)73.71(b)73.71(c)OTHER(SpecifyinAbstractbeioMandinText,HRCForm366ATOTHEREQUIREMENTSOF10CFR:Checkoneormore11LICENSEECONTACTFORTHISLER12HAMEJohnT~St.Hartin-Director,OperatingExperienceTELEPHONENUMBER(IncludeAreaCode)(315)524-4446C<NPLETEONELINEFOREACHC<NPONENTFAILUREDESCRIBEDINTHISREPORT13CAUSESYSTEHCOHPOHEHTHANUFACTURERREPORTABLETONPRDS%%)3%@i4jgc0pQWp:CAUSESYSTEHCOMPOHEHTHANUFACTURERREPORTABLETONPRDSSUPPLEMENTALREPORTEXPECTED14YES(Ifyes,completeEXPECTEDSUBHISSIOHDATE).XEXPECTEDSUBMISSIONDATE(15)MONTHDAYYEARABSTRACT(Limitto1400spaces,i.e.,approximately15single-spacedtypewrittentines)(16)Theplantwasathotshutdowncondition,withareactorstartup-inprogress.At0644ESTthereactortrippedonHighSourceRangeFluxLevel(>/=lE5countspersecond).TheunderlyingcausewasdeterminedtobeaControlRoomoperatornotadeguatelyfocusedonapproachingthereactortripsetpoint.WithtwostatuslightsburnedoutandamisleadingPPCSalarmmessage,theoperatorwasfocusedonPermissiveP-6setpointinsteadofthereactortripsetpoint.(ThiseventisNUREG-1220(A)causecode.)Correctiveactionsweretoreplacethestatuslights,correctthePPCSalarmmessage,andapprisetheControlRoomoperatorsoftheneedtofocusonreactortripsetpoints.CorrectiveactiontoprecluderepetitionisoutlinedinSectionV(B).NRCFORH366(5-92)

I NRCFORH366A(5-92)U.SIN)CLEARREGULATORYCOIIISSIQILICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYQQNO.3150-0104EXPIRES5/31/95ESTIHATEDBURDENPERRESPONSETOCONPLYllITHTHISIHFORNATIOHCOLLECTIOHREQUEST:50.0HRS.FORlIARDCONNEHTSREGARDIHGBURDENESTIHATETOTHEINFORHATIONANDRECORDSHANAGEHENTBRANCH(NHBB7714),U.S.NUCLEARREGULATORYCOHHISSIOHgllASHIHGTON,DC20555-0001ANDTOTHEPAPERlSRKREDUCTIOHPROJECT(3140-0104),OFFICEOFHANAGENENTANDBUDGETMASHINGTONDC20503.FACILITYNAHE1R.E.GinnaNuclearPowerPlantDOCKETN(NBER2YEAR05000244'3LERNIMBER6SEOUEHTIAL--007-REVISION00PAGE32OF7TEXT(Ifmorespaceisrequired,useadditionalcopiesofHRCForm366A)(17)PRE-EVENTPLANTCONDITIONSTheplantwasstableinthehotshutdowncondition,andthereactorwassubcriticalwithareactorstartupinprogress,usingprocedure0-1.2(PlantStartupFromHotShutdowntoFullLoad).II.DESCRIPTIONOFEVENTA.DATESANDAPPROXIMATETIMESOFMAJOROCCURRENCES:oNovember22,1993,0644EST:Eventdateandtime.oNovember22,1993,0644EST:Discoverydateandt'ime.oNovember22,1993,0644EST:ControlRoomoperatorsverifybothreactortripbreakersopen,andallcontrolandshutdownrodsinserted.oNovember22,1993,0650EST:Plantstabilizedathotshutdowncondition.B.EVENT:Atapproximately0643EST,theControlRoomoperatorswereconductingthefinalapproachtocriticality,inaccordancewithprocedure0-1.2.Theoperatorperformingthereactorstartupwasmovingcontrolrodsouttoestablishapositivestartuprate(SUR)priortodeclaringthereactorcritical.Atthistime,thetwoNuclearInstrumentSystem(NIS)SourceRange(SR)instrumentswereindicatingreactorpower.atapproximately5E4countspersecond(CPS).TheControlRoomoperatorwasanticipatingthatPermissiveP-6statuslightswouldilluminateatthistime,priortoexceedingthereactortripsetpointof1E5CPS.PermissiveP-6setpointisgeneratedfromNISIntermediateRange(IR)channels,when1of2channelsisabove1E-10amps.Thisisnormallyequivalenttoapproximately1E4CPSindicationontheSR'instruments.PermissiveP-6allowstheControlRoom,operatortomanuallyblocktheHighSourceRangeFluxLevelreactortripandde-energizetheSRdetectors.NRCFORM366A(5-92)

NRCFORH366A(5-92)U.S.NUCLEARREGULATORYCNHIISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBY(NBNO.3150-0104EXPIRES5/31/95ESTIHATEDBURDENPERRESPONSETOCOHPLYWiTHTHISINFORHATIONCOLLECTIOHREQUEST:50.0HRS~FORWARDCONHENTSREGARDIHGBURDENESTIHATETOTHEINFORMATIONAHDRECORDSHANAGEHEHTBRANCH(HHBB7714),U.S.NUCLEARREGULATORYCOHHISSIOH,WASHINGTON,DC205550001AHDTOTHEPAPERWORKREDUCTIONPROJECt(3150-0104),OFFICEOFHANAGEHENTAHDBUDGETWASHINGTONDC20503.FACILITYNAHE1R.E.GinnaNuclearPowerPlantDOCKETNNBER.2YEAR0500024493LERNNBER6SEQUEHTIAL-007--REVISION00PAGE33OF7TEXT(Ifmorespaceisrequired,useadditionatcopiesofHRCForm366A)(17)PriortotheP-6statuslightsilluminating,atapproximately0644EST,thereactortrippedonHighSourceRangeFluxLevel()/=1E5CPS).TheControlRoomoperatorsperformedtheappropriateactionsofEmergencyOperatingProcedureE-0(ReactorTriporSafetyInjection),andverifiedthatsafetyinjectionwasnotactuatedorrequired.TheythentransitionedtoEmergencyOperatingProcedureES-0.1(ReactorTripResponse).The-plantwassubsequentlystabilizedinhotshutdown,usingprocedure0-2.1(NormalShutdown'toHotShutdown).C~INOPERABLESTRUCTURESgCOMPONENTS/ORSYSTEMSTHATCONTRIBUTEDTOTHEEVENT:oThelightbulbsforthestatuslightsthatprovideindicationthatreactorpowerisabovePermissiveP-6werebothburnedout.oPlantProcessComputerSystem(PPCS)alarmmessagetoindicatereactorpowerisabovePermissiveP-6wasmisleading.WithreactorpowerabovetheP-6setpoint,thePPCSalarmmessageindicatedthatpowerwasstillbelowthesetpoint.D.OTHERSYSTEMSORSECONDARYFUNCTIONSAFFECTED:NoneE.METHODOFDISCOVERY:ThiseventwasimmediatelyapparentduetoMainControlBoardAnnunciatorD-26(SourceRangeHiFluxLevelReactorTriplE5CPS)andotheralarmsandindicationsintheControlRoom.HRCFORH366A(592)

II NRCFORH366A(5-92)U.S.INCLEARREGULATORYCONISSIONAPPROVEDBY(NQNO.3150-0104EXPIRES5/31/95LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONESTIHATEDBURDENPERRESPOHSETOCOHPLYMITHTHISINFORHATIONCOLLECTIOHREOUEST:50.0HRS.FORMARDCOHHEH'ISREGARDINGBURDENESTIHATETOTHEIHFORHATIOHANDRECORDSHANAGEHEHTBRANCH(HNBB7714),U.S.NUCLEARREGULATORY,COHHISSION,MASHINGTOH,DC20555-0001ANDTOTHEPAPERNNKREDUCTIONPROJECT(3'I40-0104),OFFICEOFHANAGEHENTANDBUDGETMASHINGTONDC20503.FACILITYlOWE1R.E.GinnaNuclearPowerPlantDOCKETNNIBER2YEAR0500024493LERNINBER6SEOUENTIAL-007--REVISION00PAGE34OF7TEXT(Ifmorespaceisrequired,useadditionalcopiesofHRCForm366A)(17)F.OPERATORACTION:Afterthereactortrip,theControlRoomoperatorsperformedtheappropriateactionsofEmergencyOperatingProceduresE-0(ReactorTriporSafetyInjection)andES-0.1(ReactorTripResponse).Theplantwasstabilizedathotshutdown.Subsequently,theControlRoomoperatorsnotifiedhighersupervision.TheNuclearRegulatoryCommissionwasnotifiedper10CFR50.72,Non-Emergency,4HourNotificationatapproximately1022EST.G.SAFETYSYSTEMRESPONSES:NoneIII.CAUSEOFEVENTA.IMMEDIATECAUSE:ThereactortripwasduetoNISSRhighfluxlevelabovetheSRreactortripsetpointof1E5CPS.B.INTERMEDIATECAUSE:ThehighfluxlevelwascausedbyfailuretoblocktheSRreactortrip,afterestablishingaSURofapproximately0.5to1decadesperminute(DPM)duringthefinalapproachtocriticality,withpowerapproachingtheSRreactortripsetpoint.NRCFORH366A(5-92)

NRCFORM366A(5-92)U.S.NUCLEARREGULATORYCOHISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBY0$NO.3150-0104EXPIRES5/31/95ESTIMATEDBURDEHPERRESPOHSETOCOMPLYMITHTHISIHFORHATIOHCOLLECTIONREQUEST:50.0"HRS.FORMARDCOMMENTSREGARDIHGBURDENESTIMATETOTHEINFORHATIONANDRECORDSMANAGEHEHTBRANCH(HHBB7714),U.S.NUCLEARREGULATORYCDMHISSIOH~MASHINGTOH,DC20555-0001AHDTOTHEPAPERNORKREDUCTIONPROJECT(31i0-0104),OFFICEOFMANAGEMENTANDBUDGETMASHINGTONDC20503.FACILITYNAME1R.E.GinnaNuclearPowerPlantDOCKETIRHIBER205000244YEAR93-007--00LERMINBER6SEQUENTIALREVISIONPAGE35OF7TEXT(Ifmorespaceisrequired,useadditionalcopiesofHRCForm366A)(17)C.ROOTCAUSE:TheunderlyingcauseofthefailuretoblocktheSRreactortripwithpowerincreasingata0.5to1DPMSUR,wascognitivepersonnelerrorbyaControlRoomoperator.TheControlRoomoperatorwasnotadequatelyfocusedonapproachingtheSR.reactortripsetpoint.TheControlRoomoperatorwasanticipatingthatthestatuslightsindicatingreactorpowerabovePermissiveP-6setpointwouldbeilluminated,allowingblockoftheSR-reactortrip,priortoreachingthetripsetpoint.Hisattentionwasfocusedonthesestatuslightsinsteadofontheapproachtothereactortripsetpoint.Thestatuslightsdidnotilluminateduetothelightbulbsbeingburnedout.ThePPCSalarmmessageprovidedincorrectreinforcementthatreactorpowerwasstillbelowtheP-6setpoint.Theactionsoftheoperatorperformingthereactorstartupwerenotcontrarytoproceduresestablishedforthisevolution.(ThiseventisNUREG-1220(A)causecode,PersonnelError.)IV.ANALYSISOFEVENTThiseventisreportableinaccordancewith10CFR50.73,LicenseeEventReportSystem,item(a)(2)(iv),whichrequiresareportof,"anyeventorconditionthatresultedinmanualorautomaticactuationofanyengineeredsafetyfeature(ESF)includingthereactorprotectionsystem(RPS)".ThereactortripwasanautomaticactuationoftheRPS.Anassessmentwasperformedconsideringboththesafetyconsequencesandimplicationsofthiseventwiththefollowing~resultsandconclusions:Therewerenosafetyconsequencesorimplicationsattributedtothereactortripbecause:oThetworeactortripbreakersopenedasrequired.oAllcontrolandshutdownrodsinsertedas=-designed./oTheplantwasstabilizedathotshutdown.HRCFORM366A(5-92)

NRCFORH366A(5-92)U.S.IR)CLEARREGULATORYCQIIISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDBYQGINO.3150-0104EXPIRES5/31/95ESTIHATEDBURDEHPERRESPONSETOCOHPLYMITHTHISIHFORHATIOHCOLLECTIOHREQUEST:50.0HRS.FORllARDCOHHEHTSREGARDIHGBURDENESTIHATETOTHEIHFORHATIOHANDRECORDSHANAGEHEHTBRANCH(HHBB7714),U.S.NUCLEARREGULATORYCOHHISSIOH,'WASHINGTON,DC20555-0001AHDTOTHEPAPERIQRKREDUCTIONPROJECT(3140-0104),OFFICEOFHAHAGEHEHTAHDBUDGETNASHIHGTOHDC20503.FACILITYNAHE1DOCKETNIMBER2LERNLSIBER6SEQUENTIALREVISIOHPAGE3R.E.GinnaNuclearPowerPlant'500024493"-007--00'OF7TEXT(lfmorespaceisrequired,useadditionalcopiesofHRCForm366A)(Tl)Thereactortripdidnotcauseanyreactorcoolantsystem(RCS)transient,asthere'actorwasnotatthepointofaddingheat.Allreactorprotectioncircuitryactuatedasdesignedtoplacethereactorinatrippedmodeathotshutdown.Basedontheaboveandareviewofposttripdataandpastplanttransients,itcanbeconcludedthattheplantoperatedasdesignedandthat*therewerenounreviewedsafetyquestionsandthatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVEACTIONA.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENTNORMALSTATUS:oThelightbulbsforthestatuslightsthatindicatereactorpowerisaboveP-6werereplaced,andasurveillanceprocedurewasperformedtoverifytheirfunctionality.oThePPCSalarmmessageforP-6wascorrectedtoensureaclearunderstandingofthestatusofPermissiveP-6.0OperationsManagementreevaluatedtheirexpectationsforanappropriateapproachtocriticalityatfluxlevelsneartheSRreactortripsetpoint,andcommunicatedtheserevisedexpectationstothepersonnelontheOperatingShiftscheduledtoperformthesubsequentreactorstartup.B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:,0Procedure0-1.2wasrevisedtoincorporatetherevisedmanagementexpectations.Theseincludedproceduralguidancefor(1)aconservativepowerlevel(belowtheSRreactortripsetpoint),wherethepowerincreaseshouldbestoppedtoevaluatethestatusofP-6,ifP-6statuslightshavenotilluminated,(2)aconservativeSURwhentheSRreactortripsetpointisnotdefeated,(3)aformalizedshiftbriefingconductedbytheShiftSupervisor,priortocommencingareactorstartup.NRCFORH366A(5-92)

NRCFORH366A(5-92)U.SNICLEARREGULATORYCOHISSIOHLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONNAPPROVEDBYQHINO.3150-0104EXPIRES5/31/95ESTIHATEDBURDENPERRESPONSETOCONPLYillTHTHISINFORHATIONCOLLECTIONREQUEST:50.0HRS~FORllARDCONHENTSREGARDIHGBURDENESTINATETOTHEINFORHATIONAHDRECORDSHANAGEHEHTBRAHCH(HHBB7714),U.S.NUCLEARREGULATORYCONHISSIOHgMASHIHGTOH,DC20555-0001AHDTOTHEPAPERMORKREDUCTIONPROJECT(3140-0104),OFFICEOFHANAGENENTANDBUDGETNASHIHGTONDC20503.FACILITYl6WE1R.E.GinnaNuclearPowerPlantDOCKETNl(BER20500024493-007--00LERNNBER6YEARSEQUENTIALREVISIONPAGE37OF7TEXT(lfmorespace00isrequired,useadditionalcopiesofHRCForm366A)(17)PersonnelontheOperatingShiftscheduledtoperformthesubsequentreactorstartupweretrainedontherevisionstoprocedure0-1.2priortocommencingthestartup.AHumanPerformanceEnhancementSystem(HPES)evaluationwasperformedtodeterminecausalfactorsforthisevent.The.resultsoftheHPESevaluationwereusedtoidentifytherootcauseandappropriatecorrectiveactions.0ThetwoControlRoomoperatorsdirectlyinvolvedinthis.reactortripwereremovedfromshiftuntiltheyhadcompletedadditionalsimulatortrainingonreactorstartups,andhadbeenapprisedoftherevisedmanagementexpectationscontainedintherevisiontoprocedure0-1.2.00All.licensedreactoroperators,aspartofnormaltraining,willbetrainedontherevisionstoprocedure0-1.2.AppropriatelessonplansfortheLicensedOperatorTrainingprogramswillberevisedtoensuremanagementexpectationscontainedinprocedure0-1.2arecontinuallyreinforcedduringsimulatortraining.VI.ADDITIONALINFORMATIONA.FAILEDCOMPONENTS:NoneB.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistorical.searchwasconductedwiththefollowingresults:NodocumentationofsimilarLEReventswiththesamerootcauseatGinnaNuclearPowerPlantcouldbeidentified.C.SPECIALCOMMENTS:NoneHRCFORN366A(5-92) 7