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{{#Wiki_filter:ACCELERATEDDISJBUTIONDEMONST~IONSYSTEMREGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RXDS)ACCESSIONNBR:9103130115DOC.DATE:91/03/08NOTARIZED:NOFACIL:50-244RobertEmmetGinnaNuclearPlant,Unit,1,RochesterGAUTH.NAMEAUTHORAFFILIATIONBACKUS,W.H.RochesterGas&ElectricCorp.MECREDY,R.C.RochesterGas&ElectricCorp.RECIP.NAMERECIPIENTAFFILIATIONDOCKET05000244
{{#Wiki_filter:ACCELERATED DISJBUTION DEMONST~ION SYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RXDS)ACCESSION NBR:9103130115 DOC.DATE:91/03/08NOTARIZED:
NOFACIL:50-244 RobertEmmetGinnaNuclearPlant,Unit,1,Rochester GAUTH.NAMEAUTHORAFFILIATION BACKUS,W.H.
Rochester Gas&ElectricCorp.MECREDY,R.C.
Rochester Gas&ElectricCorp.RECIP.NAME RECIPIENT AFFILIATION DOCKET05000244


==SUBJECT:==
==SUBJECT:==
LER90-017-01:on901212,twoDCswitchesopenedcausingdisablingofmanualautomaticactuationofsafeguardssequenceinitiation.Causedbyinadequateprocedures.Proceduresrevised.W/910308ltr.DISTRIBUTIONCODE:IE22DCOPXESRECEIVED:LTRENCLSIZE:TITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.NOTES:LicenseExpdateinaccordancewith10CFR2,2.109(9/19/72).D05000244ADRECIPIENTIDCODE/NAMEPD1-3LAJOHNSON,AINTERNAL:ACNWAEOD/DSP/TPABNRR/DET/ECMB9HNRR/DLPQ/LHFB11NRR/DOEA/OEABNRR/DST/SELB8DNLBBD102RGN1FILE01EXTERNAL:EG&GBRYCE,J.HNRCPDRNSICMURPHY,G.ACOPIESLTTRENCL1111221111111111111111331111RECIPIENTIDCODE/NAMEPD1-3PDAEOD/DOAAEOD/ROAB/DSPNRR/DET/EMEB7ENRR/DLPQ/LPEB10NRR/DREP/PRPB11NRR/DST/SICB7ENRR/DST/SRXB8ERES/DSIR/EIBLSTLOBBYWARDNSXCMAYS,GNUDOCSFULLTXTCOPIESLTTRENCL11112211112211.11'1111111DRtyfl'tY+~fDNOTETOALL"RIDS"RECIPIENTS:PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMP1-37(EXT.20079)TOELIMINATEYOURNAMEFROMDISTRIBUTIONLISTSFORDOCUMENTSYOUDON'TNEED!TOTALNUMBEROFCOPIESREQUIRED:LTTR31ENCL31DD n
LER90-017-01:on 901212,two DCswitchesopenedcausingdisabling ofmanualautomatic actuation ofsafeguards sequenceinitiation.
C~'iltd~~~lfllkl!Ill!~ROCHESTERGASANDELECTRICCORPORATIONROBERTC.MECREDYVicePresidentCinnaNuclearProducrionrroarsrAsc~89EASTAVENUE,ROCHESTERN.Y.14649-0001TELEPHONEAREACOOET16546'2700March8,1991U.S.NuclearRegulatoryCommissionDocumentControlDeskWashington,DC20555
Causedbyinadequate procedures.
Procedures revised.W/910308 ltr.DISTRIBUTION CODE:IE22DCOPXESRECEIVED:LTR ENCLSIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:License Expdateinaccordance with10CFR2,2.109(9/19/72).
D05000244ADRECIPIENT IDCODE/NAME PD1-3LAJOHNSON,A INTERNAL:
ACNWAEOD/DSP/TPAB NRR/DET/ECMB 9HNRR/DLPQ/LHFB11 NRR/DOEA/OEAB NRR/DST/SELB 8DNLBBD102RGN1FILE01EXTERNAL:
EG&GBRYCE,J.H NRCPDRNSICMURPHY,G.A COPIESLTTRENCL1111221111111111111111331111RECIPIENT IDCODE/NAME PD1-3PDAEOD/DOAAEOD/ROAB/DSP NRR/DET/EMEB 7ENRR/DLPQ/LPEB10 NRR/DREP/PRPB11 NRR/DST/SICB 7ENRR/DST/SRXB 8ERES/DSIR/EIB LSTLOBBYWARDNSXCMAYS,GNUDOCSFULLTXTCOPIESLTTRENCL11112211112211.11'1111111DRtyfl'tY+~
fDNOTETOALL"RIDS"RECIPIENTS:
PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMP1-37(EXT.20079)TOELIMINATE YOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!TOTALNUMBEROFCOPIESREQUIRED:
LTTR31ENCL31DD n
C~'iltd~~~lfllkl!Ill!~
ROCHESTER GASANDELECTRICCORPORATION ROBERTC.MECREDYVicePresident CinnaNuclearProducrion rroarsrAsc~89EASTAVENUE,ROCHESTER N.Y.14649-0001 TELEPHONE AREACOOET16546'2700March8,1991U.S.NuclearRegulatory Commission DocumentControlDeskWashington, DC20555


==Subject:==
==Subject:==
LER90-017,(Revision1)OpeningofDCSwitches(ProceduralInadequacy)DisablesManualandAutoActuationofSafeguardsSequenceInitiationCausingaConditionOutsidetheDesignBasisofthePlantR.E.GinnaNuclearPowerPlantDocketNo.50-244Inaccordancewith10CFR50.73,LicenseeEventReportSystem,item(a)(2)(ii)(B),whichrequiresareportof,"anyeventorconditionthatresultedintheconditionofthenuclearpowerplant,includingitsprincipalsafetybarriers,beingseriouslydegraded,orresultedinthenuclearpowerplantbeinginaconditionthatwasoutsidethedesignbasisoftheplant",theattachedLicenseeEventReportLER90-017isherebysubmitted.ThisrevisionisnecessarytorevisesectionIV(AnalysisofEvent)duetonewinformationbeingreceived.Thiseventhasinnowayaffectedthepublic'shealthandsafety.Vertrulyyours,OLcRobertC.Mecedyxc:U.S.NuclearRegulatoryCommissionRegionI475AllendaleRoadKingofPrussia,PA19406GinnaUSNRCSeniorResidentInspector910313011591030SPDRADOCK05000244SPDR
LER90-017,(Revision 1)OpeningofDCSwitches(Procedural Inadequacy)
DisablesManualandAutoActuation ofSafeguards SequenceInitiation CausingaCondition OutsidetheDesignBasisofthePlantR.E.GinnaNuclearPowerPlantDocketNo.50-244Inaccordance with10CFR50.73,LicenseeEventReportSystem,item(a)(2)(ii)(B),
whichrequiresareportof,"anyeventorcondition thatresultedinthecondition ofthenuclearpowerplant,including itsprincipal safetybarriers, beingseriously
: degraded, orresultedinthenuclearpowerplantbeinginacondition thatwasoutsidethedesignbasisoftheplant",theattachedLicenseeEventReportLER90-017isherebysubmitted.
Thisrevisionisnecessary torevisesectionIV(Analysis ofEvent)duetonewinformation beingreceived.
Thiseventhasinnowayaffectedthepublic'shealthandsafety.Vertrulyyours,OLcRobertC.Mecedyxc:U.S.NuclearRegulatory Commission RegionI475Allendale RoadKingofPrussia,PA19406GinnaUSNRCSeniorResidentInspector 9103130115 91030SPDRADOCK05000244SPDR


~IACAeeaeIN>>O$1LICENSEEEVENTREPORTILER)UAIIVCLIAAAIOVLATOAVCOINIMAINAceAovlooNIINL$IN0lovCA&VIIII/$1/~ICACIUTYNAeellllR.E.GinnaNuclearPowerPlantOOCAITNve>>IAQl06000244TOf15"'~'"OpeningofDCSwitchesDisablesManualandAutoActuationoSafeguardsenceIn>.tiation,CausinaConditionOutsidetheDesiBasisofthePlantUONTIIOAYYCA1IVCNTOATSIIIYCAILCANVe>>CAIIIII0UIeIe>AL~eUUe~1AevAaUewlweAAleOATOATIIhUONTNOAYYIAAOOCAITNVUICA>>I06000~ACIUTYN*ULIOTNI1CACIUTIIIINVOLVIOell121290900170103089106000OeIAATINOIIOOCI~I~OIVCALCVILppIILINNIIIILIIO.CNIeIllIIllIO.ANWIIII>>IIOANWIIII>>I$O.CNWIIIIIIXTN>>ACCOAT>>WIUITTIOeVAIUAN'fTIl.eOIIIITl.eNleINMlellllNMWQIN.f$WQIIIIN.f$4IQIIIIN.TSleIQIIWlN.TIWQIININ.NNIQhetN,fIIIIQlleelNPINIQIIIAAIAI~O.f$NIIIIIe>>I>>lIO.TIWQllal0TIIC1lovl1CUINTIoeIlcJAIIIceaeaeee<<aUaeelVU'Ua<<wel11111LTIILITATIWoTIIIA/CaaaafIeAAaaeateaN<<eaclaTeeLNAc/N<<SCCA/lICINICICONTACTCOATNIILC1ILTINAUITILCIUONINUUIIAWesleyH.BackusAAIACOOlTechnicalAssistanttotheOperationsManager315524-446COeeellfIONILINCCOACACNCoeeeONCNTCAILUACOIICAIIIOUeTN>>AICOAT11$1CAUIIIYITIUcoee/oNINTUANU/ACiTVIICACAUIIlVlflieCOUIONINTUANUCACTUAIAleOATAILTONTIIOIWAWIVYYLIUINTALAIIOATIAeICTIOIleeYll/I/fee,aaeUeeNCCJCCTCOCVCNIIIIONOATC/~ACTAACT/LeaeeeeleoIUea<<,I.A,eA<<eeeaeaea/IINaaIUceewcelfceeaIINaAeevliceIxeICTIOWIIIICCIONOATIIIII1:Ygaa'(%j""'$>gg~UONTIICAYYCANOnDecember12,1990,at2310EST,withthereactoratapproximately34fullpower,theControlRoomForemanopenedtwoDCswitches,asdirectedbyaMaintenanceprocedure,causingthedisablingofmanual(pushbutton)andautomaticactuationofthesafeguardssequenceinitiation.ThetwoDCswitcheswereclosed,asdirectedbytheMaintenanceprocedure,approximatelytwenty(20)minuteslater,restoringmanual(pushbutton)andautomaticactuationinitiation.Theunderlyingcauseoftheeventwasprocedureinadequacyduetoinsufficientattentiontodetail.Extensivecorrectiveactionsarebeingtakentopreventrecurrence,includingcommunicationofmanagementexpectations,HPESevalua-tions,identifyingproceduralinadequacies,andacomprehensiveupgradeoftheprocedurechange'process.IIACe<<eIN>>4$l  
~IACAeeaeIN>>O$1LICENSEEEVENTREPORTILER)UAIIVCLIAAAIOVLATOA VCOINIMAIN AceAovlooNIINL$IN0lovCA&VIIII/$1/~ICACIUTYNAeellllR.E.GinnaNuclearPowerPlantOOCAITNve>>IAQl06000244TOf15"'~'"OpeningofDCSwitchesDisablesManualandAutoActuation oSafeguards enceIn>.tiation, CausinaCondition OutsidetheDesiBasisofthePlantUONTIIOAYYCA1IVCNTOATSIIIYCAILCANVe>>CAIIIII0UIeIe>AL~eUUe~1AevAaUewlweAAleOATOATIIhUONTNOAYYIAAOOCAITNVUICA>>I06000~ACIUTYN*ULIOTNI1CACIUTIII INVOLVIOell121290900170103089106000OeIAATINO IIOOCI~I~OIVCALCVILppIILINNIIIILIIO.CNIeIllIIllIO.ANWIIII>>IIOANWIIII>>I$O.CNWIIIIII XTN>>ACCOAT>>WIUITTIOeVAIUAN'f TIl.eOIIIITl.eNleINMlellllNMWQIN.f$WQIIIIN.f$4IQIIIIN.TSleIQIIWlN.TIWQIINI N.NNIQhet N,fIIIIQlleelNPINIQIIIAAIAI~O.f$NIIIIIe>>I>>l IO.TIWQllal 0TIIC1lovl1CUINTI oeIlcJAIIIceaeaeee<<aUaeelVU'Ua<<wel11111LTIILITATIWoTIIIA/CaaaafIeAAaaeateaN<<eacla TeeLNAc/N<<SCCA/lICINICICONTACTCOATNIILC1ILTINAUITILCIUONI NUUIIAWesleyH.BackusAAIACOOlTechnical Assistant totheOperations Manager315524-446COeeellfIONILINCCOACACNCoeeeONCNT CAILUACOIICAIIIO UeTN>>AICOAT11$1CAUIIIYITIUcoee/oNINT UANU/ACiTVIICACAUIIlVlflieCOUIONINT UANUCACTUAIAleOATAILTONTIIOIWAWIVYYLIUINTAL AIIOATIAeICTIOIleeYll/I/fee,aaeUeeNCCJCCTCOCVCNIIIION OATC/~ACTAACT/LeaeeeeleoIUea<<,I.A,eA<<eeeaeaea
/IINaaIUceewcelfceeaIINa AeevliceIxeICTIOWIIIICCION OATIIIII1:Ygaa'(%j""'$>gg~UONTIICAYYCANOnDecember12,1990,at2310EST,withthereactoratapproximately 34fullpower,theControlRoomForemanopenedtwoDCswitches, asdirectedbyaMaintenance procedure, causingthedisabling ofmanual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation.
ThetwoDCswitcheswereclosed,asdirectedbytheMaintenance procedure, approximately twenty(20)minuteslater,restoring manual(pushbutton) andautomatic actuation initiation.
Theunderlying causeoftheeventwasprocedure inadequacy duetoinsufficient attention todetail.Extensive corrective actionsarebeingtakentopreventrecurrence, including communication ofmanagement expectations, HPESevalua-tions,identifying procedural inadequacies, andacomprehensive upgradeoftheprocedure change'process.
IIACe<<eIN>>4$l  


MACfons$00AI00$ILICENSEEEVENTREPORTILERITEXTCONTINUATIONV.$,IIVCLTAIIACOULATOIIYCOMMISSIONAffAOV$0OM$HOTI$0MIOOf$IIfIA%$$ITI4$fACILITYIIAM0IIIOOCIIKTIIVM0$IIITILTIIIIVM0$III~IoeQVTnTIALSUMsovlsslnSM~SfAO$ITIR.E.GinnaNuclear~PlantTSCTIJfesseONCeeNeoooe.seeOeeeesolJVIICfons~'elIITIosooo244900170102orl5PRE-EVR2lTPLANTCONDITIONSTheplantwasintheprocessofstartingupsubsequent'totheplanttripof12/ll/90(discussedinLER90-013).Thereactorwasatapproximately34fullpower,awaitingclearancethatsecondarychemistryparameterswerewithinspecification.ThetwoControlRoomreactoroperatorswereprovidingfulltimeattentiontomaintainingsteamgeneratorwaterlevel(i.e.using"manual"controloffeedwateraddition)andcontrollingreactivityduetoaXenontransient(i.e.withmanualcontrolofboronconcentration).Atapproximately2044EST,December12,1990,theControlRoomreceivedMainControlBoardAlarmL-14(Bus14UnderVoltageSafeguards).Duetothisundervoltagefailure,the"A"EmergencyDieselGeneratorautomaticallystarted.Bydesign,itdidnotcloseintoBus14asBus14wasstillpoweredbyitsnormalsupply.TheControlRoomoperatorsdispatchedauxiliaryoperators(AO)tochecktheBus14UndervoltageMonitoringSystemCabinetsintheAuxiliaryBuildingandRelayRoom.OneoftheAO'sreportedtotheControlRoomoperatorsthattheBus14UndervoltageMonitoringSystemCabinetintheAuxiliaryBuildinghadaburntodorandtherelayindicatinglightsindicatedthatatleastonerelaywasnotoperable.ThiseventisdiscussedinLER90-015.TheOperationsShiftSupervisor.(SS)notifiedstationelectriciansoftheaboveindications.ThestationelectriciansthencheckedtheBus14UndervoltageMonitoringSystemCabinetsandfoundafaultysolidstateswitchprintedcircuitboardintheAuxiliaryBuildingBus14UndervoltageMonitoringSystemCabinet.ThesefindingswerereportedtotheControlRoom.vsCfOAQ$00Ateal  
MACfons$00AI00$ILICENSEEEVENTREPORTILERITEXTCONTINUATION V.$,IIVCLTAII ACOULATOIIY COMMISSION AffAOV$0OM$HOTI$0MIOOf$IIfIA%$$ITI4$fACILITYIIAM0IIIOOCIIKTIIVM0$IIITILTIIIIVM0$III~IoeQVTnTIAL SUMsovlsslnSM~SfAO$ITIR.E.GinnaNuclear~PlantTSCTIJfesseONCeeNeoooe.seeOeeeesolJVIICfons~'elIITIosooo244900170102orl5PRE-EVR2lT PLANTCONDITIONS Theplantwasintheprocessofstartingupsubsequent'to theplanttripof12/ll/90(discussed inLER90-013).Thereactorwasatapproximately 34fullpower,awaitingclearance thatsecondary chemistry parameters werewithinspecification.
ThetwoControlRoomreactoroperators wereproviding fulltimeattention tomaintaining steamgenerator waterlevel(i.e.using"manual"controloffeedwater addition) andcontrolling reactivity duetoaXenontransient (i.e.withmanualcontrolofboronconcentration).
Atapproximately 2044EST,December12,1990,theControlRoomreceivedMainControlBoardAlarmL-14(Bus14UnderVoltageSafeguards).
Duetothisundervoltage failure,the"A"Emergency DieselGenerator automatically started.Bydesign,itdidnotcloseintoBus14asBus14wasstillpoweredbyitsnormalsupply.TheControlRoomoperators dispatched auxiliary operators (AO)tochecktheBus14Undervoltage Monitoring SystemCabinetsintheAuxiliary BuildingandRelayRoom.OneoftheAO'sreportedtotheControlRoomoperators thattheBus14Undervoltage Monitoring SystemCabinetintheAuxiliary Buildinghadaburntodorandtherelayindicating lightsindicated thatatleastonerelaywasnotoperable.
Thiseventisdiscussed inLER90-015.TheOperations ShiftSupervisor
.(SS)notifiedstationelectricians oftheaboveindications.
Thestationelectricians thencheckedtheBus14Undervoltage Monitoring SystemCabinetsandfoundafaultysolidstateswitchprintedcircuitboardintheAuxiliary BuildingBus14Undervoltage Monitoring SystemCabinet.ThesefindingswerereportedtotheControlRoom.vsCfOAQ$00Ateal  


~<<ACSccNcSSSA$4SI'LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONV.S.NVCLSAIIASOULATOIIYCOMMISSIONAft<<OVSOOMSNOSISOMIOCS)tPIIISS4ISI/ISSACILITYHAM%IIIR.E.GinnaNuclearPowerPlantTKXTIllcNrr<<WcerctowecI.uMCcNH<<crlITIC%%d~'CIIITIOOClcKTHVMISAITIosooo244LSIINVMSSIIISINSAIISCOVCNTIALASV<<IONNvccTN~NvrCr9001701AAOSISI03pal5TheStationElectricalPlannertheninitiated,"WorkRequestorTroubleReport"Number9024136,reviewedapplicabledrawingsandpreparedaworkpackage(i.e.workordernumber9024136)whichincludedPORCapprovedMain-tenanceprocedureM-48.14(XsolationofBus14UndervoltageSystemforMaintenance,Troubleshooting,ReworkandTesting).TheworkpackagewasthenreviewedbythePlannerSchedulerforcomplianceswithadministrativerequirements.TheElectricalPlannerthenperformedrequirednotificationsoftheQCEngineerandaResultsandTesttechnician,andbriefedthemonthecontentsoftheworkpackage.TheElectricalPlannertooktheworkpackagetotheElectricShopandrevieweditwiththetwoelectricianswhoweretoperformthework.TheElectricalPlannerandtwoelectricianswenttotheControlRoomandreviewedtheM-48.14.procedurewiththeSS.TheSSperformedareviewoftheM-48.14proceduretoapprovethestepsfortransferringelectricalloadsonBus14tothe"A"EmergencyDieselGenerator.TheSSthengavetheM-48.14proceduretotheControlRoomForeman(CRF)toactuallyperformtheoperationalsteps.WhentheCRFbegantoreadstep5.5.1ofM-4814,hestoppedandquestionedtheElectricalPlannerconcerningthisstep.Step5.5.1requiredtheopeningoftwoDCswitches.TheCRFwasconcernedwiththeeffectofopeningthesetwoDCswitches,giventhecurrentplantconditions.Therefore,theCRFandElectricalPlannerreviewedtheXnitialConditionsofM-48.14,andre-verifiedthattheywereadheringtotheprocedurerequirements.TheElectricalPlannerstatedtotheCRFthatthisprocedurehadbeenperformedbefore.NACAOAMSSSAI04)I  
~<<ACSccNcSSSA$4SI'LICENSEEEVENTREPORT(LER)TEXTCONTINUATION V.S.NVCLSAIIASOULATOIIY COMMISSION Aft<<OVSOOMSNOSISOMIOCS)tPIIISS 4ISI/ISSACILITYHAM%IIIR.E.GinnaNuclearPowerPlantTKXTIllcNrr<<WcerctowecI.uMCcNH<<crlITIC%%d~'CIIITIOOClcKTHVMISAITIosooo244LSIINVMSSIIISINSAIISCOVCNTIAL ASV<<IONNvccTN~NvrCr9001701AAOSISI03pal5TheStationElectrical Plannertheninitiated, "WorkRequestorTroubleReport"Number9024136,reviewedapplicable drawingsandpreparedaworkpackage(i.e.workordernumber9024136)whichincludedPORCapprovedMain-tenanceprocedure M-48.14(Xsolation ofBus14Undervoltage SystemforMaintenance, Troubleshooting, ReworkandTesting).
TheworkpackagewasthenreviewedbythePlannerScheduler forcompliances withadministrative requirements.
TheElectrical Plannerthenperformed requirednotifications oftheQCEngineerandaResultsandTesttechnician, andbriefedthemonthecontentsoftheworkpackage.TheElectrical PlannertooktheworkpackagetotheElectricShopandrevieweditwiththetwoelectricians whoweretoperformthework.TheElectrical Plannerandtwoelectricians wenttotheControlRoomandreviewedtheM-48.14.procedure withtheSS.TheSSperformed areviewoftheM-48.14procedure toapprovethestepsfortransferring electrical loadsonBus14tothe"A"Emergency DieselGenerator.
TheSSthengavetheM-48.14procedure totheControlRoomForeman(CRF)toactuallyperformtheoperational steps.WhentheCRFbegantoreadstep5.5.1ofM-4814,hestoppedandquestioned theElectrical Plannerconcerning thisstep.Step5.5.1requiredtheopeningoftwoDCswitches.
TheCRFwasconcerned withtheeffectofopeningthesetwoDCswitches, giventhecurrentplantconditions.
Therefore, theCRFandElectrical PlannerreviewedtheXnitialConditions ofM-48.14,andre-verified thattheywereadheringtotheprocedure requirements.
TheElectrical PlannerstatedtotheCRFthatthisprocedure hadbeenperformed before.NACAOAMSSSAI04)I  


MACterm444A(044ILICENSEEEVENTREPORT{LER)TEXTCONTINUATIONU.4.IIUCL4*II14OULATOAYCOMMI44IOHAttAOYEOOM4HO4I50&1044IItIII4$4I414$tACILITYIIAM4IIIOOCK4TIIUM44ALTIL4IIIIUM44III4I$4OV4rTIAI.rvr114VISIOrM~1tAO4I4IR.E.GinnaNuclearPowerPlantTEXTIJIrrttrrcerrrvteAt>>trrr4trtNIICAtnr~'tIlIllo5ooo24490-01701040Fl5DESCRIPTIONOFEVENTA.DATESANDAPPROXIMATETIMESOFMAZOROCCURRENCES:oDecember12,1990,2310ST:EventDateandTime(i.e.SIDCswitchesopened)oDecember12,1990,2330EST:SIDCswitchesclosedoDecember13,1990,0102EST:EventDiscoveryDateandTimeoDecember13,1990,0150EST:NuclearRegulatoryCommission(NRC)notifiedviaEmergencyNotificationSystem(ENS)B.FASTOnDecember12,1990at2310EST,withthereactoratapproximately34fullpower,theCRFopenedthe.twoDCswitches(requiredbystep5.5.1ofM-48.14)inthe'DCdistributionpanelsonthebackoftheControlBoard.TheopeningoftheseswitchescausedControlBoardAlarmL-31(SafeguardsDCFailure)toannunciate.Thereceiptofthisalarmwasquestionedatthe,time,buttheresponsefromtheCRFwasthatthealarmwasanexpectedresultofperformingstep5.5.1ofM-48.14.FurtherevaluationofthisalarmwasdeferredtocontinuewithM-48.14.TheCRF,continuingwithM-48.14,openedtheBus14NormalFeedBreakertoallowthe"A"EmergencyDieselGeneratortotieintoBus14.Thisactionresultedinmomentarilyde-energizingthe1BInstrumentBus.ThereactortriprelayfromNuclearInstrumentationSystemIntermediateRangeChannelN-36(poweredfromthisBus)de-energizedandareactortripoccurred.ThereactortripisdiscussedinLER90-016.MACtOAM444Ai444I  
MACterm444A(044ILICENSEEEVENTREPORT{LER)TEXTCONTINUATION U.4.IIUCL4*II 14OULATOAY COMMI44IOH AttAOYEOOM4HO4I50&1044IItIII4$
4I414$tACILITYIIAM4IIIOOCK4TIIUM44ALTIL4IIIIUM44III4I$4OV4rTIAI.rvr114VISIOrM~1tAO4I4IR.E.GinnaNuclearPowerPlantTEXTIJIrrttrrcerrrvteAt>>trrr4trtNIICAtnr~'tIlIllo5ooo24490-01701040Fl5DESCRIPTION OFEVENTA.DATESANDAPPROXIMATE TIMESOFMAZOROCCURRENCES:
oDecember12,1990,2310ST:EventDateandTime(i.e.SIDCswitchesopened)oDecember12,1990,2330EST:SIDCswitchesclosedoDecember13,1990,0102EST:EventDiscovery DateandTimeoDecember13,1990,0150EST:NuclearRegulatory Commission (NRC)notifiedviaEmergency Notification System(ENS)B.FASTOnDecember12,1990at2310EST,withthereactoratapproximately 34fullpower,theCRFopenedthe.twoDCswitches(required bystep5.5.1ofM-48.14)inthe'DCdistribution panelsonthebackoftheControlBoard.TheopeningoftheseswitchescausedControlBoardAlarmL-31(Safeguards DCFailure)toannunciate.
Thereceiptofthisalarmwasquestioned atthe,time,buttheresponsefromtheCRFwasthatthealarmwasanexpectedresultofperforming step5.5.1ofM-48.14.Furtherevaluation ofthisalarmwasdeferredtocontinuewithM-48.14.TheCRF,continuing withM-48.14,openedtheBus14NormalFeedBreakertoallowthe"A"Emergency DieselGenerator totieintoBus14.Thisactionresultedinmomentarily de-energizing the1BInstrument Bus.ThereactortriprelayfromNuclearInstrumentation SystemIntermediate RangeChannelN-36(poweredfromthisBus)de-energized andareactortripoccurred.
Thereactortripisdiscussed inLER90-016.MACtOAM444Ai444I  


MACTerna$44AISAILICENSEEEVENTREPORT(LER)TEXTCONTINUATIONV.S.IIVCLSAA1SOULATOAYCOMMISSIOMA99AOVSOOMSMOSISOWIOl/SIItllISSSISI4$/ACILITYIIAM4IIIR.E.GinnaNuclearPowerPlantTscTwrrr9racerrrrrAvieeeeeewsACerr~SIIITIOOCIISTMVMSSIII!Iosooo24490LSIIMVMSSIIISITaovlrnALHUMAaSYOIQ>~yM10,5QF15TheControlRoomoperatorsimmediatelyperformedtheapplicableactionsofE-0(ReactorTriporSafetyInjection)andES-0.1(ReactorTripResponse)andstabilizedtheplantinhotshutdown.AftercompletingtheapplicablestepsofE-0andES-0.1,theControlRoomoperatorscompletedtheirpartofM-48.14,byclosingthetwoDCswitchesthathadbeenopenedinstep5.5.1ofM-48.14.Thiswasaccomplishedatapproximately2330EST,December12,1990.TheoncomingSS,whohadbeenintheControlRoomduringthisevent,resumedtheevaluationoftheconsequencesofalarmL-31afterplantconditionshadstabilized.(Thecauseofthealarmhadalreadybeendetermined.)HeperformedanotherreviewofM-48.14andcalledotherknowledgeablemembersoftheplantstaffattheirhomes(atapproximately0100EST,December13,1990)todiscusshisconcernsabouttheeffectofopeningthesetwoDCswitches.Afterreceivingconfirmationthathisconcernswerelegiti-mate,hemadethepropernotificationstohighersupervisionandtheNuclearRegulatoryCommission(NRC).C.D.E.INOPERABLESTRUCTURES4COMPONENTS4ORSYSTEMSTHATCONTRIBUTEDTOTHELRG%T:None.OEMSYSTEMSORSECONDARYFUNCTIONSAFFECTED:None.METHOD'OFDIScommY:TheeventwasmadeapparentduringtheoncomingSSreviewoftheconsequencesofControlBoardAlarmL-31(SafeguardsDCFailure)andsubsequentdiscussionswithknowledgeableplantstaff.MACSOAM$44A>94$I 0
MACTerna$44AISAILICENSEEEVENTREPORT(LER)TEXTCONTINUATION V.S.IIVCLSAA1SOULATOAY COMMISSIOM A99AOVSOOMSMOSISOWIOl/SIItllISS SISI4$/ACILITYIIAM4IIIR.E.GinnaNuclearPowerPlantTscTwrrr9racerrrrrAvieeeeeewsACerr~SIIITIOOCIISTMVMSSIII!Iosooo24490LSIIMVMSSIIISITaovlrnAL HUMAaSYOIQ>~yM10,5QF15TheControlRoomoperators immediately performed theapplicable actionsofE-0(ReactorTriporSafetyInjection) andES-0.1(ReactorTripResponse) andstabilized theplantinhotshutdown.
MACtorwaaaAIS4alLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONV.S.IIVCLSAIIASOVLATOIIYCOMMISSIOHAffAOVSOOMSHOSISO&104arflASSSISI4SfACILITYNAMaIIIoocraTIlvMaarIalI,allIIVMaallIalSCOVCHTIAL%VMARa+IQIOHMSA~AOaIalR.E.GinnaNuclearPowerPlantTaxTIIIneveMMfee~~oeaecverA'cfonsIa'llII'5ooo24490-0170106ovl5POPERATORACTION:Factorsthatinfluencedoperatoractionsduringtheeventwereasfollows:0TheControlRoomoperatorsquestionedstep5.5.1inprocedureM-48.14,butinformationinM-48.14,theDCswitchlabels,andAlarmResponseprocedure.AR-L-31didnotprovidesufficientoperationalinformationtodeterminetheconsequencesofopeningthesetwoswitches.oTheControlRoomoperatorshadconfidenceinaPlantOperatingReviewCommittee(PORC)approvedprocedurethathadalsobeenreviewedbytheElectricalPlanner.Astheeventwasoverpriortodiscovery,nooperatoractionsotherthannormalwereperformed.G.SAFETYSYSTEMRESPONSES:None.XXXCAUSEOPEMBFZA.IMl69)IATECAUSE:Aconditionoutsidethedesignbasisoftheplantwascausedbythedisablingofmanual(pushbutton)andautomaticactuationofthesafeguardssequenceinitiation(i.e.autoandmanualSZ).INTERMEDIATECAUSE:Thedisablingofmanual(pushbutton)andautomaticactuationofthesafeguardssequenceinitiationwascausedbyswitchf12inthelADCDistributionPanelandswitchg9inthe1BDCDistributionPanelbeingopenatthesametime.BothofthesepanelsareonthebackoftheMainControlBoard.41CSOAQSSSAla0SI  
Aftercompleting theapplicable stepsofE-0andES-0.1,theControlRoomoperators completed theirpartofM-48.14,byclosingthetwoDCswitchesthathadbeenopenedinstep5.5.1ofM-48.14.Thiswasaccomplished atapproximately 2330EST,December12,1990.TheoncomingSS,whohadbeenintheControlRoomduringthisevent,resumedtheevaluation oftheconsequences ofalarmL-31afterplantconditions hadstabilized.
(Thecauseofthealarmhadalreadybeendetermined.)
Heperformed anotherreviewofM-48.14andcalledotherknowledgeable membersoftheplantstaffattheirhomes(atapproximately 0100EST,December13,1990)todiscusshisconcernsabouttheeffectofopeningthesetwoDCswitches.
Afterreceiving confirmation thathisconcernswerelegiti-mate,hemadethepropernotifications tohighersupervision andtheNuclearRegulatory Commission (NRC).C.D.E.INOPERABLE STRUCTURES 4COMPONENTS 4ORSYSTEMSTHATCONTRIBUTED TOTHELRG%T:None.OEMSYSTEMSORSECONDARY FUNCTIONS AFFECTED:
None.METHOD'OFDIScommY:
TheeventwasmadeapparentduringtheoncomingSSreviewoftheconsequences ofControlBoardAlarmL-31(Safeguards DCFailure)andsubsequent discussions withknowledgeable plantstaff.MACSOAM$44A>94$I 0
MACtorwaaaAIS4alLICENSEEEVENTREPORT(LER)TEXTCONTINUATION V.S.IIVCLSAII ASOVLATOIIY COMMISSIOH AffAOVSOOMSHOSISO&104arflASSSISI4SfACILITYNAMaIIIoocraTIlvMaarIalI,allIIVMaallIalSCOVCHTIAL
%VMARa+IQIOHMSA~AOaIalR.E.GinnaNuclearPowerPlantTaxTIIIneveMMfee~~oeaecverA'cfonsIa'llII'5ooo24490-0170106ovl5POPERATORACTION:Factorsthatinfluenced operatoractionsduringtheeventwereasfollows:0TheControlRoomoperators questioned step5.5.1inprocedure M-48.14,butinformation inM-48.14,theDCswitchlabels,andAlarmResponseprocedure
.AR-L-31didnotprovidesufficient operational information todetermine theconsequences ofopeningthesetwoswitches.
oTheControlRoomoperators hadconfidence inaPlantOperating ReviewCommittee (PORC)approvedprocedure thathadalsobeenreviewedbytheElectrical Planner.Astheeventwasoverpriortodiscovery, nooperatoractionsotherthannormalwereperformed.
G.SAFETYSYSTEMRESPONSES:
None.XXXCAUSEOPEMBFZA.IMl69)IATE CAUSE:Acondition outsidethedesignbasisoftheplantwascausedbythedisabling ofmanual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation (i.e.autoandmanualSZ).INTERMEDIATE CAUSE:Thedisabling ofmanual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation wascausedbyswitchf12inthelADCDistribution Panelandswitchg9inthe1BDCDistribution Panelbeingopenatthesametime.BothofthesepanelsareonthebackoftheMainControlBoard.41CSOAQSSSAla0SI  


MACSons494AI94SILICENSEEEVENTREPORT(LER)TEXTCONTINUATIONV.S.IIUCLSAIIIIEOULATOAYCOMMISSIONA99ROVEOOM4ROSISOMIOAEX9IRES41414$9ACILITYIIAMEIIIR.E.GinnaNuclearPowerPlantTEXTlll~CWCeMneee4YA9aANenelCIVICAnn~ElIITIo5ooo24490LEIIHVMCEA191SSQUSNTIALHMAASYOIO>Ap7OFl5ProcedureM-48.14hadbeeninitiallywrittenin1983foruseathotorcoldshutdownconditions.In1985,theprocedurewasmodifiedtoallowuseonlyatcoldshutdownconditions.Theinitialprocedureandtherevisionsweretechnicallycorrectandreceivedamulti-disciplinedreviewandapproval.During1988,M-48.14receivedamajorrewriteandRevision6becameeffectiveMarch23,1989.ThepurposeoftherewritewastochangethemethodoffeedingBus14,andaspartofthisprocesstheplantmodewaschangedto"AnyModeofoperation."Thischangereceivedathoroughreviewpriortobecomingeffective.Onedaylater,itwaserroneouslyconcludedthatcertainsteps,whichhadpreviouslybeenintheprocedureforuseatcoldshutdown,wereinadvertentlyomittedfromthecurrentprocedure.Thus,M-48.14waschangedtoinsertthecurrentstep5.1.1.Thischangeisinappropriateinmodesotherthancoldshutdown,butthiswasnotrecognizedduringthereviewandapprovalprocess.ROOTCAUSE:Therootcausewasdeterminedtobefailureoftheorganizationtoattributesufficientattentiontodetailintheprocedurechangeprocess.00AMaintenanceprocedurewhichwaspreviouslycorrect,waschangedtorequireinappropriateactions,inthattheproceduredirectedtheopeningofswitchesintheDCpowersupplytotheSIsequencesduringallmodesofoperation.TheprocedurewasreviewedbythePlantOperatingReviewCommitteeandapprovedforusebyplantmanagement,forallmodesofplantoperation,althoughtheopeningofthetwoDCswitcheswasclearlyintendedforuseatcoldshutdownconditionstopreventspuriousSIactuationduringBustransfertotheEmergencyDieselGenerators.+ACAOAM444Ai9441  
MACSons494AI94SILICENSEEEVENTREPORT(LER)TEXTCONTINUATION V.S.IIUCLSAII IIEOULATOAY COMMISSION A99ROVEOOM4ROSISOMIOAEX9IRES41414$9ACILITYIIAMEIIIR.E.GinnaNuclearPowerPlantTEXTlll~CWCeMneee4YA9aANenelCIVICAnn~ElIITIo5ooo24490LEIIHVMCEA191SSQUSNTIAL HMAASYOIO>Ap7OFl5Procedure M-48.14hadbeeninitially writtenin1983foruseathotorcoldshutdownconditions.
In1985,theprocedure wasmodifiedtoallowuseonlyatcoldshutdownconditions.
Theinitialprocedure andtherevisions weretechnically correctandreceivedamulti-disciplined reviewandapproval.
During1988,M-48.14receivedamajorrewriteandRevision6becameeffective March23,1989.ThepurposeoftherewritewastochangethemethodoffeedingBus14,andaspartofthisprocesstheplantmodewaschangedto"AnyModeofoperation."
Thischangereceivedathoroughreviewpriortobecomingeffective.
Onedaylater,itwaserroneously concluded thatcertainsteps,whichhadpreviously beenintheprocedure foruseatcoldshutdown, wereinadvertently omittedfromthecurrentprocedure.
Thus,M-48.14waschangedtoinsertthecurrentstep5.1.1.Thischangeisinappropriate inmodesotherthancoldshutdown, butthiswasnotrecognized duringthereviewandapprovalprocess.ROOTCAUSE:Therootcausewasdetermined tobefailureoftheorganization toattribute sufficient attention todetailintheprocedure changeprocess.00AMaintenance procedure whichwaspreviously correct,waschangedtorequireinappropriate actions,inthattheprocedure directedtheopeningofswitchesintheDCpowersupplytotheSIsequences duringallmodesofoperation.
Theprocedure wasreviewedbythePlantOperating ReviewCommittee andapprovedforusebyplantmanagement, forallmodesofplantoperation, althoughtheopeningofthetwoDCswitcheswasclearlyintendedforuseatcoldshutdownconditions topreventspuriousSIactuation duringBustransfertotheEmergency DieselGenerators.
+ACAOAM444Ai9441  


NNCSereM($4SIL'ICENSEEEVENTREPORTILERITEXTCONTINUATIONV.S.NVCLSANACOULATOIIYCOMMISSIONASSAOYKOOMSNOS1$0&IOS/$NSIII%$SISI4$FACILITYNANtIIIOOCISKTNUMCSIIISILlllNVMOSIIIIISSQUSNTIAI,M1ASYISIONM~A~AOSIS)R.E.GinnaNuclearPowerPlantTEXTIN'maoMSCeNnerre4~~HIICANM~'SlIIllosooo24490-017-080F15Acontributingfactoristheneedforaquestion-ingattitude.TheCRF,inquestioningtheperformanceofstep5.1.1ofM-48.14,didnotgofarenoughwithhisquestioningattitude.XV.ANALYSTSOFEVENTThiseventisreportableinaccordancewith10CFR50.73,LicenseeEventReportSystem,item(a)(2)(ii)(B),whichrequiresareportof"anyeventorconditionthatresultedintheconditionofthenuclearpowerplant,includingitsprincipalsafetybarriers,beingseriouslydegraded,orresultedinthenuclearpowerplantbeinginaconditionthatwasoutsidethedesignbasisoftheplant",inthatthedisablingofmanual(pushbutton)andautomaticactuationofthesafeguardssequenceinitiationplacedtheplantinaconditionoutsideitsdesignbasis.Anassessmentwasperformedconsideringboththesafetyconsequencesandimplicationsofthiseventwiththefollowingresultsandconclusions:Duringtheaboveevent,manual(pushbutton)andautomaticactuationofthesafeguardssequenceinitiationwasdisabled,however,thevariouspumpsandvalveswereoperableandcouldbeoperatedbytheControlBoard'witches.TheControlRoomoperatorsperformimmediateactionsuponreactortripperprocedureE-0.Throughtheseproceduralimmediateactionstheoperatorsevaluatewhetheraconditionrequiringsafetyinjectionexists,andifrequired,verifyoperationofsafeguardsequipmentormanuallystartandalignthatequipment.Theirevaluationwouldbebasedupontheappropriateannunciatoralarms(allofwhichwereunaffectedbytheDCswitchpositions),orareviewofcontrolboardparameterindications(i.e.RCSpressure,SteamGeneratorpressure,etc.).NACSONMSSSA<~ASI  
NNCSereM($4SIL'ICENSEE EVENTREPORTILERITEXTCONTINUATION V.S.NVCLSANACOULATOIIY COMMISSION ASSAOYKOOMSNOS1$0&IOS/$NSIII%$SISI4$FACILITYNANtIIIOOCISKTNUMCSIIISILlllNVMOSIIIIISSQUSNTIAI, M1ASYISIONM~A~AOSIS)R.E.GinnaNuclearPowerPlantTEXTIN'maoMSCeNnerre4~~HIICANM~'SlIIllosooo24490-017-080F15Acontributing factoristheneedforaquestion-ingattitude.
TheCRF,inquestioning theperformance ofstep5.1.1ofM-48.14,didnotgofarenoughwithhisquestioning attitude.
XV.ANALYSTSOFEVENTThiseventisreportable inaccordance with10CFR50.73,LicenseeEventReportSystem,item(a)(2)(ii)(B),
whichrequiresareportof"anyeventorcondition thatresultedinthecondition ofthenuclearpowerplant,including itsprincipal safetybarriers, beingseriously
: degraded, orresultedinthenuclearpowerplantbeinginacondition thatwasoutsidethedesignbasisoftheplant",inthatthedisabling ofmanual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation placedtheplantinacondition outsideitsdesignbasis.Anassessment wasperformed considering boththesafetyconsequences andimplications ofthiseventwiththefollowing resultsandconclusions:
Duringtheaboveevent,manual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation wasdisabled, however,thevariouspumpsandvalveswereoperableandcouldbeoperatedbytheControlBoard'witches.
TheControlRoomoperators performimmediate actionsuponreactortripperprocedure E-0.Throughtheseprocedural immediate actionstheoperators evaluatewhetheracondition requiring safetyinjection exists,andifrequired, verifyoperation ofsafeguards equipment ormanuallystartandalignthatequipment.
Theirevaluation wouldbebasedupontheappropriate annunciator alarms(allofwhichwereunaffected bytheDCswitchpositions),
orareviewofcontrolboardparameter indications (i.e.RCSpressure, SteamGenerator
: pressure, etc.).NACSONMSSSA<~ASI  


ISWCiona00SAI043ILICENSEEEVENTREPORTILERITEXTCONTINUATIONV.S.IIuCLSASIASOVLATOIIYCOMMISNOII/ASSAOYlOOM0HO0ISOWIOS%)ttlAllSI314SFACILITYIIAMlIIIOOCIIKTIIUMllAIllLlllMOMOSIII~ISSQMSNTIAL'SVOIO>MA'MS1R.E.GinnaNuclear~PlantTEXTIFWaOCWOtAteyWet,~ASASOASIIYJICAnti~'SIIITIosooo2449001701090sl5Theeffectofthepotentialdelayinactuatingsafeguardsequipmentuponthose.eventsanalyzedintheUFSARwasevaluated.TheaccidentseffectedbythisactionarethoseaccidentswhichresultindepressurizationoftheprimarysystemcausingSI.Theseareprimarilythefollowing:oFeedLineBreak(FLB)oSteamGeneratorTubeRupture(SGTR)oSmallBreakLossofCoolantAccident(SBLOCA)oLargeBreakLossofCoolantAccident(LOCA)oSmallSteamLineBreak(SmallSLB)oLargeSteamLineBreak(SLB)Ananalysisoftheseaccidentswasperformedtodeterminetheeffectofthedisablingofmanual(pushbutton)andautomaticactuationofthesafeguardssequenceinitiationwiththefollowingresults:FeedLineBreakThisaccidentwasanalyzedbytheGinnaUpdatedFinalSafetyAnalysisReport(UFSAR)as'heatupeventwithauxiliaryfeedwateravailableinten(10)minutes.Asaheatupevent,RCSpressureneverdecreasedbelowtheSIsetpoint,butrapidlyincreasedabovetheSIpumpshutoffhead.Therefore,SIwasnotnecessaryandauxiliaryfeedwater,whenavailablewithinten(10)minutes,issufficienttomitigatetheevent.Operatoractionstostartauxiliaryfeedwaterwithinten(10)minutesisconsistentwiththeGinnalicensingbasis.IftheFLBwasre-evaluatedasacooldowneventfrom34powertheresultswouldbeboundedbyaSLB.VAC+0AMSSSA<l00I  
ISWCiona00SAI043ILICENSEEEVENTREPORTILERITEXTCONTINUATION V.S.IIuCLSASI ASOVLATOIIY COMMISNOII
/ASSAOYlOOM0HO0ISOWIOS%)ttlAllSI314SFACILITYIIAMlIIIOOCIIKTIIUMllAIllLlllMOMOSIII~ISSQMSNTIAL
'SVOIO>MA'MS1R.E.GinnaNuclear~PlantTEXTIFWaOCWOtAteyWet,~ASASOASIIYJICAnti~'SIIITIosooo2449001701090sl5Theeffectofthepotential delayinactuating safeguards equipment uponthose.eventsanalyzedintheUFSARwasevaluated.
Theaccidents effectedbythisactionarethoseaccidents whichresultindepressurization oftheprimarysystemcausingSI.Theseareprimarily thefollowing:
oFeedLineBreak(FLB)oSteamGenerator TubeRupture(SGTR)oSmallBreakLossofCoolantAccident(SBLOCA)oLargeBreakLossofCoolantAccident(LOCA)oSmallSteamLineBreak(SmallSLB)oLargeSteamLineBreak(SLB)Ananalysisoftheseaccidents wasperformed todetermine theeffectofthedisabling ofmanual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation withthefollowing results:FeedLineBreakThisaccidentwasanalyzedbytheGinnaUpdatedFinalSafetyAnalysisReport(UFSAR)as'heatupeventwithauxiliary feedwater available inten(10)minutes.Asaheatupevent,RCSpressureneverdecreased belowtheSIsetpoint, butrapidlyincreased abovetheSIpumpshutoffhead.Therefore, SIwasnotnecessary andauxiliary feedwater, whenavailable withinten(10)minutes,issufficient tomitigatetheevent.Operatoractionstostartauxiliary feedwater withinten(10)minutesisconsistent withtheGinnalicensing basis.IftheFLBwasre-evaluated asacooldowneventfrom34powertheresultswouldbeboundedbyaSLB.VAC+0AMSSSA<l00I  


MAC4reSSSAITSILICENSEEEVENTREPORTILERITEXTCONTINUATIONV.S.IIUCLEAIIASOULATOIIYCOMMISNOIeASSAOVKOOM9kO9ISONICS/SIISIA9$SISI4$SACILITYIIASSSIllOOCIICTIIUMSKRIllLSIIMUM99llISISSQVSNTIALSVMAA9VISIONMSA~AOSISIR.E.GinnaNuclearPowerPlantTaXTIIT~MMCSe~eeSSA9SAMAIACrenemaSIIITIosooo2449001701100F15SteamGeneratorTubeRutureSGTRisboundedbySBLOCAfromtheRCSdepressurizationstandpoint.TheleakratefromaSGTRis,smallcomparedtobreakflowforaSBLOCA.Thereisnosignificanteffectduetolackofmanual(pushbutton)orautomaticSIsincethemainstepsintheproceduredealwithisolationoftherupturedSG,depressurizationoftheRCS,andterminationofSI.SmallBreakLossofCoolantAccidentWhenmanual(pushbutton)andautomaticSIwasde-activated,thereactorwasoperatingat34power.Thereactorhadbeenat34powerforapproximatelyten(10)hours.Priortothat,thereactorhadbeensubcriticalfortwenty-two(22)hoursfollowingatrip.WestinghouseOwner'sGroupletterWOG90-113,datedJuly2,1990,"ShutdownLOCAProgram-DraftReport",evaluatedamode4LOCAusingagenerictwo(2)loopplantwithasix(6)inchbreakassumedtooccurtwoandahalf(2.5)hoursaftershutdown.AcceptableresultswereobtainedprovidedSIwasstartedten(10)minutesafterthebreak.Assumptionsofthemode4LOCAanalysis'arecomparedwiththeGinnaEventconditionsbelow:WOGMODE4GINNAEVENTDecayHeat1.34NoaccumulatorsavailableRCSpressure1000psigRCStemperature425oFDecayHeat0.534AccumulatorsavailableRCSpressure2235psigRCStemperature547FTheavailabilityofaccumulatorsandthelowerdecayheatoffsetthehigherRCStemperatureandpressure.SufficienttimeisavailabletomanuallystarttheSIandRHRpumpsandopenappropriatevalvesfromtheControlRoom,andtorecoverfromtheSBLOCA.Inanycase,SBLOCAisboundedbyLOCAbecauselesstimeisavailableforoperatoractionduringaLargeBreakLOCA.Nocreditwastakenforchargingflowwhichbyitselfcouldhaveremovedapproximatelythatlevelofdecay~heat.VACSCAMSSSAi9All  
MAC4reSSSAITSILICENSEEEVENTREPORTILERITEXTCONTINUATION V.S.IIUCLEAII ASOULATOIIY COMMISNOIe ASSAOVKOOM9kO9ISONICS/SIISIA9$SISI4$SACILITYIIASSSIllOOCIICTIIUMSKRIllLSIIMUM99llISISSQVSNTIAL SVMAA9VISIONMSA~AOSISIR.E.GinnaNuclearPowerPlantTaXTIIT~MMCSe~eeSSA9SAMAIACrenemaSIIITIosooo2449001701100F15SteamGenerator TubeRutureSGTRisboundedbySBLOCAfromtheRCSdepressurization standpoint.
TheleakratefromaSGTRis,smallcomparedtobreakflowforaSBLOCA.Thereisnosignificant effectduetolackofmanual(pushbutton) orautomatic SIsincethemainstepsintheprocedure dealwithisolation oftherupturedSG,depressurization oftheRCS,andtermination ofSI.SmallBreakLossofCoolantAccidentWhenmanual(pushbutton) andautomatic SIwasde-activated, thereactorwasoperating at34power.Thereactorhadbeenat34powerforapproximately ten(10)hours.Priortothat,thereactorhadbeensubcritical fortwenty-two (22)hoursfollowing atrip.Westinghouse Owner'sGroupletterWOG90-113,datedJuly2,1990,"Shutdown LOCAProgram-DraftReport",evaluated amode4LOCAusingagenerictwo(2)loopplantwithasix(6)inchbreakassumedtooccurtwoandahalf(2.5)hoursaftershutdown.
Acceptable resultswereobtainedprovidedSIwasstartedten(10)minutesafterthebreak.Assumptions ofthemode4LOCAanalysis'arecomparedwiththeGinnaEventconditions below:WOGMODE4GINNAEVENTDecayHeat1.34Noaccumulators available RCSpressure1000psigRCStemperature 425oFDecayHeat0.534Accumulators available RCSpressure2235psigRCStemperature 547FTheavailability ofaccumulators andthelowerdecayheatoffsetthehigherRCStemperature andpressure.
Sufficient timeisavailable tomanuallystarttheSIandRHRpumpsandopenappropriate valvesfromtheControlRoom,andtorecoverfromtheSBLOCA.Inanycase,SBLOCAisboundedbyLOCAbecauselesstimeisavailable foroperatoractionduringaLargeBreakLOCA.Nocreditwastakenforchargingflowwhichbyitselfcouldhaveremovedapproximately thatlevelofdecay~heat.
VACSCAMSSSAi9All  


NNCfor>>SSSA(S4SI''ICENSEEEVENTREPORTILERITEXTCONTINUATIONU.S.NUCLlAN1SOULATOIIYCOMMISSIONAff1OVSOOMSNOSISO&I04/tllfl1SS'SISI4SfACILITYNAMSIIIOOCKSTNUMSSII11ILt1NUMSSNISISSQUSNTIALASVISIONNUM1INM~A~AOSQIR.E.GinnaNuclearPowerPlantTSICTIN'a>>Ce>>>>SVfff.vlfOS>>SOANlVACfWse~VIIITIosooo24490Ol70111OF15LareBreakLossofCoolantAccidentAnassessmentofdisablingmanual(pushbutton)andautomaticSIat34powerwasperformedbyWestinghousewithrespecttotheLOCAanalysis.TheassessmentassumedtheRCSwasat547F,2235psig.Thefuelrodswereassumedtobeat600Fwhichwouldbetheapproximatepelletandcladtemperatureattheend-of-blowdownphase.Thevessellowerplenumandthelowerportionofthecorewouldbecoveredwithaccumulatorwater.Further,itwasassumedthat,SImustbeinitiatedwhenthefuelrodsareat1800Ftoturnaroundthecladdingtemperaturebeforeitreaches2200F.Decayheatisbasedonanapproximationofpowerhistorypriortotheevent,usingthe1971ANSModel.Anadiabaticheatupcalculationwasperformedusingpropertiesfora14x14arrayOptimumFuelAssembly(OFA).ThecalculationindicatedSIwasnecessaryinapproximately14minutes.SimulationsontheGinnaspecificsimulatorindicatealessthan2minuteoperatorresponseduringaLOCAisachievable.SmallSteamLineBreakThisaccidentisboundedbytheLargeSLBbecauselongertimesareavailableforoperatorresponse.LareSteamLineBreakWestinghouseassessedtheeffectofnomanual(pushbutton)orautomaticSIontheSteamLineBreakanalysis.BasedontheirexperienceswithSteamLineBreakanalysisaswellasareviewoftheavailablemargintotheacceptancecriteria,itwasjudgedthatiftheaccidentwerere-analyzedat34powerwithnomanual(pushbutton)orautomaticSI,acceptableresultswouldbeobtained.41CfOAQSSSAiSASI  
NNCfor>>SSSA(S4SI''ICENSEE EVENTREPORTILERITEXTCONTINUATION U.S.NUCLlAN1SOULATOIIY COMMISSION Aff1OVSOOMSNOSISO&I04/tllfl1SS'SISI4SfACILITYNAMSIIIOOCKSTNUMSSII11ILt1NUMSSNISISSQUSNTIAL ASVISIONNUM1INM~A~AOSQIR.E.GinnaNuclearPowerPlantTSICTIN'a>>Ce>>>>SVfff.
vlfOS>>SOANlVACfWse~VIIITIosooo24490Ol70111OF15LareBreakLossofCoolantAccidentAnassessment ofdisabling manual(pushbutton) andautomatic SIat34powerwasperformed byWestinghouse withrespecttotheLOCAanalysis.
Theassessment assumedtheRCSwasat547F,2235psig.Thefuelrodswereassumedtobeat600Fwhichwouldbetheapproximate pelletandcladtemperature attheend-of-blowdown phase.Thevessellowerplenumandthelowerportionofthecorewouldbecoveredwithaccumulator water.Further,itwasassumedthat,SImustbeinitiated whenthefuelrodsareat1800Ftoturnaroundthecladdingtemperature beforeitreaches2200F.Decayheatisbasedonanapproximation ofpowerhistorypriortotheevent,usingthe1971ANSModel.Anadiabatic heatupcalculation wasperformed usingproperties fora14x14arrayOptimumFuelAssembly(OFA).Thecalculation indicated SIwasnecessary inapproximately 14minutes.Simulations ontheGinnaspecificsimulator indicatealessthan2minuteoperatorresponseduringaLOCAisachievable.
SmallSteamLineBreakThisaccidentisboundedbytheLargeSLBbecauselongertimesareavailable foroperatorresponse.
LareSteamLineBreakWestinghouse assessedtheeffectofnomanual(pushbutton) orautomatic SIontheSteamLineBreakanalysis.
Basedontheirexperiences withSteamLineBreakanalysisaswellasareviewoftheavailable margintotheacceptance
: criteria, itwasjudgedthatiftheaccidentwerere-analyzedat34powerwithnomanual(pushbutton) orautomatic SI,acceptable resultswouldbeobtained.
41CfOAQSSSAiSASI  


MACSons$$$A1$4$1LICENSEEEVENTREPORTII.ERITEXTCONTINUATIONV.$.HUCL$AIIATOULATOIIYCOMMI$$IOMASSAOVKOOUIIIO$I$0MIOO$)IOIA$$l/$1/8$SACILITYIIAM$111RoE.GinnaNuclearPowerPlantTSITIII'ssooMMo~nooooY.oMooMMMMAtACASM~$IIITIOOCII$TIIUSM$%11Iosooo244LtllIIVMO$111$l$$CUonTIALsovlslon~IVMS'M~S9001701SAO$1$1120~15RochesterGasandElectricCorporation(RG&E)performedacomputeranalysisoftheSLBusingtheWestinghouseLOFTRANCode.AbasecasewascomparedtoacasewhereSIwasdelayedforten(10)minutes.ThecomparisonindicatednegligiblechangeinminimumDNBR.Therewasaninsigni-ficantchangeinmassreleasedtocontainmentbecausemassreleaseisdominatedbyinitialsteamgeneratorlevelandauxiliaryfeedwaterflow,neitherofwhichareaffectedbydelayedSI.Comparingenergyoutthebreakforbothcases,showednegligibledifferences.Therefore,delayingSIhasnegligibleeffectonminimumDNBRandmass/energyoutthebreak.Inconclusion,delayofmanual(pushbutton)andautomaticSIwiththereactorat34powerwouldnotcauseNon-LOCAeventstoexceedtheacceptancecriteria.Adelayofapproximately14'inutesintheLOCAcanbetoleratedwithoutunacceptableresults.Basedonoperatortraining,thisissufficienttimeforoperatorresponse.Basedontheabove,itcanbeconcludedthatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVEACTIONACTIONTAKENTORE'ZURNAFFECTEDSYSTEMSTOPRE-~9FZNORMALSTATUS:Theaffectedsystemwasrestoredtonormalwhenthetwo(2)DCswitcheswereclosedtwenty(20)minutesaftertheywereopened.VACSCAM$$$A<0'  
MACSons$$$A1$4$1LICENSEEEVENTREPORTII.ERITEXTCONTINUATION V.$.HUCL$AIIATOULATOIIY COMMI$$IOMASSAOVKOOUIIIO$I$0MIOO$)IOIA$$l/$1/8$SACILITYIIAM$111RoE.GinnaNuclearPowerPlantTSITIII'ssooMMo~nooooY.oMooMMMMAtACASM~$IIITIOOCII$TIIUSM$%11Iosooo244LtllIIVMO$111$l$$CUonTIALsovlslon~IVMS'M~S9001701SAO$1$1120~15Rochester GasandElectricCorporation (RG&E)performed acomputeranalysisoftheSLBusingtheWestinghouse LOFTRANCode.AbasecasewascomparedtoacasewhereSIwasdelayedforten(10)minutes.Thecomparison indicated negligible changeinminimumDNBR.Therewasaninsigni-ficantchangeinmassreleasedtocontainment becausemassreleaseisdominated byinitialsteamgenerator levelandauxiliary feedwater flow,neitherofwhichareaffectedbydelayedSI.Comparing energyoutthebreakforbothcases,showednegligible differences.
Therefore, delayingSIhasnegligible effectonminimumDNBRandmass/energy outthebreak.Inconclusion, delayofmanual(pushbutton) andautomatic SIwiththereactorat34powerwouldnotcauseNon-LOCAeventstoexceedtheacceptance criteria.
Adelayofapproximately 14'inutes intheLOCAcanbetolerated withoutunacceptable results.Basedonoperatortraining, thisissufficient timeforoperatorresponse.
Basedontheabove,itcanbeconcluded thatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVE ACTIONACTIONTAKENTORE'ZURNAFFECTEDSYSTEMSTOPRE-~9FZNORMALSTATUS:Theaffectedsystemwasrestoredtonormalwhenthetwo(2)DCswitcheswereclosedtwenty(20)minutesaftertheywereopened.VACSCAM$$$A<0'  


IIAC>wwSSSALICENSEEEVENTREPORTILER)TEXTCONTINUATIONV.S.IIUCLSAIIIISOULATOIIYCOMMISSIOIIASSAOYSOOMSIIO)ISO&I04/SXrlASSSISIISSSACILITYIIAMSIIIOOCIISTIIVMSSIIISILSIIIIUMS~IIISISLOMINTIALlllVISIQN~I4144~AOSISIR.E.GinnaNuclearPowerPlantosooo244900170113OF15B.ACT?ONTAKENORPLANNEDTOPREVENTRECURRENCE:ShortTermActions00SeniorManagementmetwithkeyplantpersonneltocommunicatemanagementexpecta-tionsforaquestioningattitudeandattentiontodetail.Thesegroupsincludedalltheoperatingshifts,theMaintenanceplanningstaff,andPORCmembers.PolicieswereissuedaddressingtheOpera-tionsShiftSupervisorreviewofprocedurespriortogivingauthorizationtoproceed,andtheMaintenanceplanners'esponsi-bilitiesforWorkPackagereview.0Allplantprocedureswerescreenedforpossibleoperationalimpactinadequacies,andpotentiallydeficientproceduresweremadeunavailableforuse.Proceduresthatweremadeunavailableforuse,butwereimmediatelyrequiredforsafeplantoperation,werecarefullyreviewedpriortobeingmadeavailableforuse.AHumanPerformanceEnhancementSystem(HPES)evaluationwasperformedonControlRoomactivities'associatedwiththisevent,toidentifytheneedforanyadditionalshorttermcorrectiveactions.Additionalactionswereidentified.ActionsidentifiedbytheHPESprocesswereimplementedwhereappropriate,includingadditionalupgradesofswitchlabels,amoredetailedreviewofAlarmResponseprocedures,improvedwordingofpro'ceduralstepsforHumanFactorsconcerns,andadditionalinformationtobemadeavailabletotheoperators.Forallinvolvedoperationspersonnel,theiroperatingexperienceandtraininghistorieswerereviewedforadequacy.SACAOAMSSSA(0ASI  
IIAC>wwSSSALICENSEEEVENTREPORTILER)TEXTCONTINUATION V.S.IIUCLSAII IISOULATOIIY COMMISSIOII ASSAOYSOOMSIIO)ISO&I04/SXrlASSSISIISSSACILITYIIAMSIIIOOCIISTIIVMSSIIISILSIIIIUMS~IIISISLOMINTIAL lllVISIQN
~I4144~AOSISIR.E.GinnaNuclearPowerPlantosooo244900170113OF15B.ACT?ONTAKENORPLANNEDTOPREVENTRECURRENCE:
ShortTermActions00SeniorManagement metwithkeyplantpersonnel tocommunicate management expecta-tionsforaquestioning attitudeandattention todetail.Thesegroupsincludedalltheoperating shifts,theMaintenance planningstaff,andPORCmembers.Policieswereissuedaddressing theOpera-tionsShiftSupervisor reviewofprocedures priortogivingauthorization toproceed,andtheMaintenance planners'esponsi-bilitiesforWorkPackagereview.0Allplantprocedures werescreenedforpossibleoperational impactinadequacies, andpotentially deficient procedures weremadeunavailable foruse.Procedures thatweremadeunavailable foruse,butwereimmediately requiredforsafeplantoperation, werecarefully reviewedpriortobeingmadeavailable foruse.AHumanPerformanceEnhancement System(HPES)evaluation wasperformed onControlRoomactivities
'associated withthisevent,toidentifytheneedforanyadditional shorttermcorrective actions.Additional actionswereidentified.
Actionsidentified bytheHPESprocesswereimplemented whereappropriate, including additional upgradesofswitchlabels,amoredetailedreviewofAlarmResponseprocedures, improvedwordingofpro'cedural stepsforHumanFactorsconcerns, andadditional information tobemadeavailable totheoperators.
Forallinvolvedoperations personnel, theiroperating experience andtraininghistories werereviewedforadequacy.
SACAOAMSSSA(0ASI  


NACro<<MEEEAI04)IrACILITYNAMEIllUCENSEEEVENTREPORTILER)TEXTCONTINUATIONDOCKETNVMEEAIEIVS.NVCLEAIIAEOVLATOIIYCOMMIEEIONArrROVEOOMENO3150&104E)IrIAEEEI31/8$~ACEIEI\R.E.GinnaNuclearPowerPlantTExTIh'rrrrNMrr<<Mrr<<EE.<<rEaaseowNOMICfond~'rIIITILEIINVMEEII(EI<<EAASECVENTIALAEVISIQNNMEAosooo24490017014OF10Anindependentassessmentofthestatusofshorttermactions,andoftheprocedurescreening,wasconductedbeforemanagementauthorizedrestartofthereactor.2~LongTermActions0AnHPESevaluationoftheprocedurechangeprocessisbeingperformed.Fromthisevaluation,recommendationsforlongtermimprovementswillbeimplemented.AmongtheseimprovementsaretheincreasedinvolvementofOperationsinthereviewofproposedchanges,requirementsformoreaccuratedescriptionsofproposedchanges,andmorerigorinthereviewofchangesatPORCmeetings.0Toensuretheeffectivenessoftheshorttermcorrectiveactions,follow-upevalua-tionswillbeconducted.Basedontheseevaluations,managementwilldeterminetheneedforadditionalreinforcementoftheseactions.0ThetrainingprogramsforOperationspersonnel,PORCmembers,andMaintenanceplannerswillbere-evaluated.Weexpecttomakelongtermimprovementsintheseprograms,andinthecontentoftheseprograms,and-alsointhetrainingprogramsforotherplantpersonnel.0Proceduresthatarecurrentlyunavailableforusewillbereviewedindetailpriortoreleaseforuse.Weareexpeditingthereviewofthoseprocedures,placinghighestpriorityonthoseprocedureswhichareexpectedtobeneededduringthecourseofroutineoperations,toensuretheiravail-abilityinthenearfuture.NACrOAMEEEA>EATI 0l IIACtoreSSSAIS43IL'ICENSEEEVENTREPORT(LER)TEXTCONTINUATlONV.S.IIUCLEAAAEOULATOIIYCOMMITSIOIIANNAOVEOOMSHO)ISO&IONrEXNIAES>II5145NACILITYIIAMEIIIR.E.GinnaNuclearPowerPlantTEXTIN'4eCeeteerrC~NcMOoeVIVJICAwe~1IIITIOOCKKTIIUMItllI1Iosooo244LEIIIIUMOEXINSNOUNHTIALiNSVOION4VM8HMNi9001701~AOEIll50rl50Policiesthatwereinitiatedasaresultofthiseventwillbereviewedforconsistencywithpre-existingpoliciesandprocedures.whereappropriate,existingpolicieswillbealtered,supersedingthenewpolicies.ADDXTXONALXNFORMATXONA.FAILEDCOMPONENTS:None.B.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistoricalsearchwasconductedwiththefollowingresults:NodocumentationofsimilarLEReventswiththesamerootcauseatGinnaStationcouldbeidentified.C.SPECXALCOMMENTSNone.VACNOAMSSSAiSOJI 0I}}
NACro<<MEEEAI04)IrACILITYNAMEIllUCENSEEEVENTREPORTILER)TEXTCONTINUATION DOCKETNVMEEAIEIVS.NVCLEAIIAEOVLATOIIY COMMIEEION ArrROVEOOMENO3150&104E)IrIAEEEI31/8$~ACEIEI\R.E.GinnaNuclearPowerPlantTExTIh'rrrrNMrr<<Mrr<<EE.<<rEaaseowNOMICfond~'rIIITILEIINVMEEII(EI<<EAASECVENTIAL AEVISIQNNMEAosooo24490017014OF10Anindependent assessment ofthestatusofshorttermactions,andoftheprocedure screening, wasconducted beforemanagement authorized restartofthereactor.2~LongTermActions0AnHPESevaluation oftheprocedure changeprocessisbeingperformed.
Fromthisevaluation, recommendations forlongtermimprovements willbeimplemented.
Amongtheseimprovements aretheincreased involvement ofOperations inthereviewofproposedchanges,requirements formoreaccuratedescriptions ofproposedchanges,andmorerigorinthereviewofchangesatPORCmeetings.
0Toensuretheeffectiveness oftheshorttermcorrective actions,follow-up evalua-tionswillbeconducted.
Basedontheseevaluations, management willdetermine theneedforadditional reinforcement oftheseactions.0ThetrainingprogramsforOperations personnel, PORCmembers,andMaintenance plannerswillbere-evaluated.
Weexpecttomakelongtermimprovements intheseprograms, andinthecontentoftheseprograms, and-alsointhetrainingprogramsforotherplantpersonnel.
0Procedures thatarecurrently unavailable forusewillbereviewedindetailpriortoreleaseforuse.Weareexpediting thereviewofthoseprocedures, placinghighestpriorityonthoseprocedures whichareexpectedtobeneededduringthecourseofroutineoperations, toensuretheiravail-abilityinthenearfuture.NACrOAMEEEA>EATI 0l IIACtoreSSSAIS43IL'ICENSEE EVENTREPORT(LER)TEXTCONTINUATlON V.S.IIUCLEAAAEOULATOIIY COMMITSIOII ANNAOVEOOMSHO)ISO&IONrEXNIAES>II5145NACILITYIIAMEIIIR.E.GinnaNuclearPowerPlantTEXTIN'4eCeeteerrC~NcMOoeVIVJICAwe~1IIITIOOCKKTIIUMItllI1Iosooo244LEIIIIUMOEXINSNOUNHTIAL iNSVOION4VM8HMNi9001701~AOEIll50rl50Policiesthatwereinitiated asaresultofthiseventwillbereviewedforconsistency withpre-existing policiesandprocedures.
whereappropriate, existingpolicieswillbealtered,superseding thenewpolicies.
ADDXTXONAL XNFORMATXON A.FAILEDCOMPONENTS:
None.B.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistorical searchwasconducted withthefollowing results:Nodocumentation ofsimilarLEReventswiththesamerootcauseatGinnaStationcouldbeidentified.
C.SPECXALCOMMENTSNone.VACNOAMSSSAiSOJI 0I}}

Revision as of 12:13, 29 June 2018

LER 90-017-01:on 901212,two DC Switches Opened Causing Disabling of Manual Automatic Actuation of Safeguards Sequence Initiation.Caused by Inadequate Procedures. Procedures revised.W/910308 Ltr
ML17262A409
Person / Time
Site: Ginna Constellation icon.png
Issue date: 03/08/1991
From: BACKUS W H, MECREDY R C
ROCHESTER GAS & ELECTRIC CORP.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-017, LER-90-17, NUDOCS 9103130115
Download: ML17262A409 (34)
v • d • e


Text

ACCELERATED DISJBUTION DEMONST~ION SYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RXDS)ACCESSION NBR:9103130115 DOC.DATE:91/03/08NOTARIZED:

NOFACIL:50-244 RobertEmmetGinnaNuclearPlant,Unit,1,Rochester GAUTH.NAMEAUTHORAFFILIATION BACKUS,W.H.

Rochester Gas&ElectricCorp.MECREDY,R.C.

Rochester Gas&ElectricCorp.RECIP.NAME RECIPIENT AFFILIATION DOCKET05000244

SUBJECT:

LER90-017-01:on 901212,two DCswitchesopenedcausingdisabling ofmanualautomatic actuation ofsafeguards sequenceinitiation.

Causedbyinadequate procedures.

Procedures revised.W/910308 ltr.DISTRIBUTION CODE:IE22DCOPXESRECEIVED:LTR ENCLSIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:License Expdateinaccordance with10CFR2,2.109(9/19/72).

D05000244ADRECIPIENT IDCODE/NAME PD1-3LAJOHNSON,A INTERNAL:

ACNWAEOD/DSP/TPAB NRR/DET/ECMB 9HNRR/DLPQ/LHFB11 NRR/DOEA/OEAB NRR/DST/SELB 8DNLBBD102RGN1FILE01EXTERNAL:

EG&GBRYCE,J.H NRCPDRNSICMURPHY,G.A COPIESLTTRENCL1111221111111111111111331111RECIPIENT IDCODE/NAME PD1-3PDAEOD/DOAAEOD/ROAB/DSP NRR/DET/EMEB 7ENRR/DLPQ/LPEB10 NRR/DREP/PRPB11 NRR/DST/SICB 7ENRR/DST/SRXB 8ERES/DSIR/EIB LSTLOBBYWARDNSXCMAYS,GNUDOCSFULLTXTCOPIESLTTRENCL11112211112211.11'1111111DRtyfl'tY+~

fDNOTETOALL"RIDS"RECIPIENTS:

PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMP1-37(EXT.20079)TOELIMINATE YOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!TOTALNUMBEROFCOPIESREQUIRED:

LTTR31ENCL31DD n

C~'iltd~~~lfllkl!Ill!~

ROCHESTER GASANDELECTRICCORPORATION ROBERTC.MECREDYVicePresident CinnaNuclearProducrion rroarsrAsc~89EASTAVENUE,ROCHESTER N.Y.14649-0001 TELEPHONE AREACOOET16546'2700March8,1991U.S.NuclearRegulatory Commission DocumentControlDeskWashington, DC20555

Subject:

LER90-017,(Revision 1)OpeningofDCSwitches(Procedural Inadequacy)

DisablesManualandAutoActuation ofSafeguards SequenceInitiation CausingaCondition OutsidetheDesignBasisofthePlantR.E.GinnaNuclearPowerPlantDocketNo.50-244Inaccordance with10CFR50.73,LicenseeEventReportSystem,item(a)(2)(ii)(B),

whichrequiresareportof,"anyeventorcondition thatresultedinthecondition ofthenuclearpowerplant,including itsprincipal safetybarriers, beingseriously

degraded, orresultedinthenuclearpowerplantbeinginacondition thatwasoutsidethedesignbasisoftheplant",theattachedLicenseeEventReportLER90-017isherebysubmitted.

Thisrevisionisnecessary torevisesectionIV(Analysis ofEvent)duetonewinformation beingreceived.

Thiseventhasinnowayaffectedthepublic'shealthandsafety.Vertrulyyours,OLcRobertC.Mecedyxc:U.S.NuclearRegulatory Commission RegionI475Allendale RoadKingofPrussia,PA19406GinnaUSNRCSeniorResidentInspector 9103130115 91030SPDRADOCK05000244SPDR

~IACAeeaeIN>>O$1LICENSEEEVENTREPORTILER)UAIIVCLIAAAIOVLATOA VCOINIMAIN AceAovlooNIINL$IN0lovCA&VIIII/$1/~ICACIUTYNAeellllR.E.GinnaNuclearPowerPlantOOCAITNve>>IAQl06000244TOf15"'~'"OpeningofDCSwitchesDisablesManualandAutoActuation oSafeguards enceIn>.tiation, CausinaCondition OutsidetheDesiBasisofthePlantUONTIIOAYYCA1IVCNTOATSIIIYCAILCANVe>>CAIIIII0UIeIe>AL~eUUe~1AevAaUewlweAAleOATOATIIhUONTNOAYYIAAOOCAITNVUICA>>I06000~ACIUTYN*ULIOTNI1CACIUTIII INVOLVIOell121290900170103089106000OeIAATINO IIOOCI~I~OIVCALCVILppIILINNIIIILIIO.CNIeIllIIllIO.ANWIIII>>IIOANWIIII>>I$O.CNWIIIIII XTN>>ACCOAT>>WIUITTIOeVAIUAN'f TIl.eOIIIITl.eNleINMlellllNMWQIN.f$WQIIIIN.f$4IQIIIIN.TSleIQIIWlN.TIWQIINI N.NNIQhet N,fIIIIQlleelNPINIQIIIAAIAI~O.f$NIIIIIe>>I>>l IO.TIWQllal 0TIIC1lovl1CUINTI oeIlcJAIIIceaeaeee<<aUaeelVU'Ua<<wel11111LTIILITATIWoTIIIA/CaaaafIeAAaaeateaN<<eacla TeeLNAc/N<<SCCA/lICINICICONTACTCOATNIILC1ILTINAUITILCIUONI NUUIIAWesleyH.BackusAAIACOOlTechnical Assistant totheOperations Manager315524-446COeeellfIONILINCCOACACNCoeeeONCNT CAILUACOIICAIIIO UeTN>>AICOAT11$1CAUIIIYITIUcoee/oNINT UANU/ACiTVIICACAUIIlVlflieCOUIONINT UANUCACTUAIAleOATAILTONTIIOIWAWIVYYLIUINTAL AIIOATIAeICTIOIleeYll/I/fee,aaeUeeNCCJCCTCOCVCNIIIION OATC/~ACTAACT/LeaeeeeleoIUea<<,I.A,eA<<eeeaeaea

/IINaaIUceewcelfceeaIINa AeevliceIxeICTIOWIIIICCION OATIIIII1:Ygaa'(%j""'$>gg~UONTIICAYYCANOnDecember12,1990,at2310EST,withthereactoratapproximately 34fullpower,theControlRoomForemanopenedtwoDCswitches, asdirectedbyaMaintenance procedure, causingthedisabling ofmanual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation.

ThetwoDCswitcheswereclosed,asdirectedbytheMaintenance procedure, approximately twenty(20)minuteslater,restoring manual(pushbutton) andautomatic actuation initiation.

Theunderlying causeoftheeventwasprocedure inadequacy duetoinsufficient attention todetail.Extensive corrective actionsarebeingtakentopreventrecurrence, including communication ofmanagement expectations, HPESevalua-tions,identifying procedural inadequacies, andacomprehensive upgradeoftheprocedure change'process.

IIACe<<eIN>>4$l

MACfons$00AI00$ILICENSEEEVENTREPORTILERITEXTCONTINUATION V.$,IIVCLTAII ACOULATOIIY COMMISSION AffAOV$0OM$HOTI$0MIOOf$IIfIA%$$ITI4$fACILITYIIAM0IIIOOCIIKTIIVM0$IIITILTIIIIVM0$III~IoeQVTnTIAL SUMsovlsslnSM~SfAO$ITIR.E.GinnaNuclear~PlantTSCTIJfesseONCeeNeoooe.seeOeeeesolJVIICfons~'elIITIosooo244900170102orl5PRE-EVR2lT PLANTCONDITIONS Theplantwasintheprocessofstartingupsubsequent'to theplanttripof12/ll/90(discussed inLER90-013).Thereactorwasatapproximately 34fullpower,awaitingclearance thatsecondary chemistry parameters werewithinspecification.

ThetwoControlRoomreactoroperators wereproviding fulltimeattention tomaintaining steamgenerator waterlevel(i.e.using"manual"controloffeedwater addition) andcontrolling reactivity duetoaXenontransient (i.e.withmanualcontrolofboronconcentration).

Atapproximately 2044EST,December12,1990,theControlRoomreceivedMainControlBoardAlarmL-14(Bus14UnderVoltageSafeguards).

Duetothisundervoltage failure,the"A"Emergency DieselGenerator automatically started.Bydesign,itdidnotcloseintoBus14asBus14wasstillpoweredbyitsnormalsupply.TheControlRoomoperators dispatched auxiliary operators (AO)tochecktheBus14Undervoltage Monitoring SystemCabinetsintheAuxiliary BuildingandRelayRoom.OneoftheAO'sreportedtotheControlRoomoperators thattheBus14Undervoltage Monitoring SystemCabinetintheAuxiliary Buildinghadaburntodorandtherelayindicating lightsindicated thatatleastonerelaywasnotoperable.

Thiseventisdiscussed inLER90-015.TheOperations ShiftSupervisor

.(SS)notifiedstationelectricians oftheaboveindications.

Thestationelectricians thencheckedtheBus14Undervoltage Monitoring SystemCabinetsandfoundafaultysolidstateswitchprintedcircuitboardintheAuxiliary BuildingBus14Undervoltage Monitoring SystemCabinet.ThesefindingswerereportedtotheControlRoom.vsCfOAQ$00Ateal

~<<ACSccNcSSSA$4SI'LICENSEEEVENTREPORT(LER)TEXTCONTINUATION V.S.NVCLSAIIASOULATOIIY COMMISSION Aft<<OVSOOMSNOSISOMIOCS)tPIIISS 4ISI/ISSACILITYHAM%IIIR.E.GinnaNuclearPowerPlantTKXTIllcNrr<<WcerctowecI.uMCcNH<<crlITIC%%d~'CIIITIOOClcKTHVMISAITIosooo244LSIINVMSSIIISINSAIISCOVCNTIAL ASV<<IONNvccTN~NvrCr9001701AAOSISI03pal5TheStationElectrical Plannertheninitiated, "WorkRequestorTroubleReport"Number9024136,reviewedapplicable drawingsandpreparedaworkpackage(i.e.workordernumber9024136)whichincludedPORCapprovedMain-tenanceprocedure M-48.14(Xsolation ofBus14Undervoltage SystemforMaintenance, Troubleshooting, ReworkandTesting).

TheworkpackagewasthenreviewedbythePlannerScheduler forcompliances withadministrative requirements.

TheElectrical Plannerthenperformed requirednotifications oftheQCEngineerandaResultsandTesttechnician, andbriefedthemonthecontentsoftheworkpackage.TheElectrical PlannertooktheworkpackagetotheElectricShopandrevieweditwiththetwoelectricians whoweretoperformthework.TheElectrical Plannerandtwoelectricians wenttotheControlRoomandreviewedtheM-48.14.procedure withtheSS.TheSSperformed areviewoftheM-48.14procedure toapprovethestepsfortransferring electrical loadsonBus14tothe"A"Emergency DieselGenerator.

TheSSthengavetheM-48.14procedure totheControlRoomForeman(CRF)toactuallyperformtheoperational steps.WhentheCRFbegantoreadstep5.5.1ofM-4814,hestoppedandquestioned theElectrical Plannerconcerning thisstep.Step5.5.1requiredtheopeningoftwoDCswitches.

TheCRFwasconcerned withtheeffectofopeningthesetwoDCswitches, giventhecurrentplantconditions.

Therefore, theCRFandElectrical PlannerreviewedtheXnitialConditions ofM-48.14,andre-verified thattheywereadheringtotheprocedure requirements.

TheElectrical PlannerstatedtotheCRFthatthisprocedure hadbeenperformed before.NACAOAMSSSAI04)I

MACterm444A(044ILICENSEEEVENTREPORT{LER)TEXTCONTINUATION U.4.IIUCL4*II 14OULATOAY COMMI44IOH AttAOYEOOM4HO4I50&1044IItIII4$

4I414$tACILITYIIAM4IIIOOCK4TIIUM44ALTIL4IIIIUM44III4I$4OV4rTIAI.rvr114VISIOrM~1tAO4I4IR.E.GinnaNuclearPowerPlantTEXTIJIrrttrrcerrrvteAt>>trrr4trtNIICAtnr~'tIlIllo5ooo24490-01701040Fl5DESCRIPTION OFEVENTA.DATESANDAPPROXIMATE TIMESOFMAZOROCCURRENCES:

oDecember12,1990,2310ST:EventDateandTime(i.e.SIDCswitchesopened)oDecember12,1990,2330EST:SIDCswitchesclosedoDecember13,1990,0102EST:EventDiscovery DateandTimeoDecember13,1990,0150EST:NuclearRegulatory Commission (NRC)notifiedviaEmergency Notification System(ENS)B.FASTOnDecember12,1990at2310EST,withthereactoratapproximately 34fullpower,theCRFopenedthe.twoDCswitches(required bystep5.5.1ofM-48.14)inthe'DCdistribution panelsonthebackoftheControlBoard.TheopeningoftheseswitchescausedControlBoardAlarmL-31(Safeguards DCFailure)toannunciate.

Thereceiptofthisalarmwasquestioned atthe,time,buttheresponsefromtheCRFwasthatthealarmwasanexpectedresultofperforming step5.5.1ofM-48.14.Furtherevaluation ofthisalarmwasdeferredtocontinuewithM-48.14.TheCRF,continuing withM-48.14,openedtheBus14NormalFeedBreakertoallowthe"A"Emergency DieselGenerator totieintoBus14.Thisactionresultedinmomentarily de-energizing the1BInstrument Bus.ThereactortriprelayfromNuclearInstrumentation SystemIntermediate RangeChannelN-36(poweredfromthisBus)de-energized andareactortripoccurred.

Thereactortripisdiscussed inLER90-016.MACtOAM444Ai444I

MACTerna$44AISAILICENSEEEVENTREPORT(LER)TEXTCONTINUATION V.S.IIVCLSAA1SOULATOAY COMMISSIOM A99AOVSOOMSMOSISOWIOl/SIItllISS SISI4$/ACILITYIIAM4IIIR.E.GinnaNuclearPowerPlantTscTwrrr9racerrrrrAvieeeeeewsACerr~SIIITIOOCIISTMVMSSIII!Iosooo24490LSIIMVMSSIIISITaovlrnAL HUMAaSYOIQ>~yM10,5QF15TheControlRoomoperators immediately performed theapplicable actionsofE-0(ReactorTriporSafetyInjection) andES-0.1(ReactorTripResponse) andstabilized theplantinhotshutdown.

Aftercompleting theapplicable stepsofE-0andES-0.1,theControlRoomoperators completed theirpartofM-48.14,byclosingthetwoDCswitchesthathadbeenopenedinstep5.5.1ofM-48.14.Thiswasaccomplished atapproximately 2330EST,December12,1990.TheoncomingSS,whohadbeenintheControlRoomduringthisevent,resumedtheevaluation oftheconsequences ofalarmL-31afterplantconditions hadstabilized.

(Thecauseofthealarmhadalreadybeendetermined.)

Heperformed anotherreviewofM-48.14andcalledotherknowledgeable membersoftheplantstaffattheirhomes(atapproximately 0100EST,December13,1990)todiscusshisconcernsabouttheeffectofopeningthesetwoDCswitches.

Afterreceiving confirmation thathisconcernswerelegiti-mate,hemadethepropernotifications tohighersupervision andtheNuclearRegulatory Commission (NRC).C.D.E.INOPERABLE STRUCTURES 4COMPONENTS 4ORSYSTEMSTHATCONTRIBUTED TOTHELRG%T:None.OEMSYSTEMSORSECONDARY FUNCTIONS AFFECTED:

None.METHOD'OFDIScommY:

TheeventwasmadeapparentduringtheoncomingSSreviewoftheconsequences ofControlBoardAlarmL-31(Safeguards DCFailure)andsubsequent discussions withknowledgeable plantstaff.MACSOAM$44A>94$I 0

MACtorwaaaAIS4alLICENSEEEVENTREPORT(LER)TEXTCONTINUATION V.S.IIVCLSAII ASOVLATOIIY COMMISSIOH AffAOVSOOMSHOSISO&104arflASSSISI4SfACILITYNAMaIIIoocraTIlvMaarIalI,allIIVMaallIalSCOVCHTIAL

%VMARa+IQIOHMSA~AOaIalR.E.GinnaNuclearPowerPlantTaxTIIIneveMMfee~~oeaecverA'cfonsIa'llII'5ooo24490-0170106ovl5POPERATORACTION:Factorsthatinfluenced operatoractionsduringtheeventwereasfollows:0TheControlRoomoperators questioned step5.5.1inprocedure M-48.14,butinformation inM-48.14,theDCswitchlabels,andAlarmResponseprocedure

.AR-L-31didnotprovidesufficient operational information todetermine theconsequences ofopeningthesetwoswitches.

oTheControlRoomoperators hadconfidence inaPlantOperating ReviewCommittee (PORC)approvedprocedure thathadalsobeenreviewedbytheElectrical Planner.Astheeventwasoverpriortodiscovery, nooperatoractionsotherthannormalwereperformed.

G.SAFETYSYSTEMRESPONSES:

None.XXXCAUSEOPEMBFZA.IMl69)IATE CAUSE:Acondition outsidethedesignbasisoftheplantwascausedbythedisabling ofmanual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation (i.e.autoandmanualSZ).INTERMEDIATE CAUSE:Thedisabling ofmanual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation wascausedbyswitchf12inthelADCDistribution Panelandswitchg9inthe1BDCDistribution Panelbeingopenatthesametime.BothofthesepanelsareonthebackoftheMainControlBoard.41CSOAQSSSAla0SI

MACSons494AI94SILICENSEEEVENTREPORT(LER)TEXTCONTINUATION V.S.IIUCLSAII IIEOULATOAY COMMISSION A99ROVEOOM4ROSISOMIOAEX9IRES41414$9ACILITYIIAMEIIIR.E.GinnaNuclearPowerPlantTEXTlll~CWCeMneee4YA9aANenelCIVICAnn~ElIITIo5ooo24490LEIIHVMCEA191SSQUSNTIAL HMAASYOIO>Ap7OFl5Procedure M-48.14hadbeeninitially writtenin1983foruseathotorcoldshutdownconditions.

In1985,theprocedure wasmodifiedtoallowuseonlyatcoldshutdownconditions.

Theinitialprocedure andtherevisions weretechnically correctandreceivedamulti-disciplined reviewandapproval.

During1988,M-48.14receivedamajorrewriteandRevision6becameeffective March23,1989.ThepurposeoftherewritewastochangethemethodoffeedingBus14,andaspartofthisprocesstheplantmodewaschangedto"AnyModeofoperation."

Thischangereceivedathoroughreviewpriortobecomingeffective.

Onedaylater,itwaserroneously concluded thatcertainsteps,whichhadpreviously beenintheprocedure foruseatcoldshutdown, wereinadvertently omittedfromthecurrentprocedure.

Thus,M-48.14waschangedtoinsertthecurrentstep5.1.1.Thischangeisinappropriate inmodesotherthancoldshutdown, butthiswasnotrecognized duringthereviewandapprovalprocess.ROOTCAUSE:Therootcausewasdetermined tobefailureoftheorganization toattribute sufficient attention todetailintheprocedure changeprocess.00AMaintenance procedure whichwaspreviously correct,waschangedtorequireinappropriate actions,inthattheprocedure directedtheopeningofswitchesintheDCpowersupplytotheSIsequences duringallmodesofoperation.

Theprocedure wasreviewedbythePlantOperating ReviewCommittee andapprovedforusebyplantmanagement, forallmodesofplantoperation, althoughtheopeningofthetwoDCswitcheswasclearlyintendedforuseatcoldshutdownconditions topreventspuriousSIactuation duringBustransfertotheEmergency DieselGenerators.

+ACAOAM444Ai9441

NNCSereM($4SIL'ICENSEE EVENTREPORTILERITEXTCONTINUATION V.S.NVCLSANACOULATOIIY COMMISSION ASSAOYKOOMSNOS1$0&IOS/$NSIII%$SISI4$FACILITYNANtIIIOOCISKTNUMCSIIISILlllNVMOSIIIIISSQUSNTIAI, M1ASYISIONM~A~AOSIS)R.E.GinnaNuclearPowerPlantTEXTIN'maoMSCeNnerre4~~HIICANM~'SlIIllosooo24490-017-080F15Acontributing factoristheneedforaquestion-ingattitude.

TheCRF,inquestioning theperformance ofstep5.1.1ofM-48.14,didnotgofarenoughwithhisquestioning attitude.

XV.ANALYSTSOFEVENTThiseventisreportable inaccordance with10CFR50.73,LicenseeEventReportSystem,item(a)(2)(ii)(B),

whichrequiresareportof"anyeventorcondition thatresultedinthecondition ofthenuclearpowerplant,including itsprincipal safetybarriers, beingseriously

degraded, orresultedinthenuclearpowerplantbeinginacondition thatwasoutsidethedesignbasisoftheplant",inthatthedisabling ofmanual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation placedtheplantinacondition outsideitsdesignbasis.Anassessment wasperformed considering boththesafetyconsequences andimplications ofthiseventwiththefollowing resultsandconclusions:

Duringtheaboveevent,manual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation wasdisabled, however,thevariouspumpsandvalveswereoperableandcouldbeoperatedbytheControlBoard'witches.

TheControlRoomoperators performimmediate actionsuponreactortripperprocedure E-0.Throughtheseprocedural immediate actionstheoperators evaluatewhetheracondition requiring safetyinjection exists,andifrequired, verifyoperation ofsafeguards equipment ormanuallystartandalignthatequipment.

Theirevaluation wouldbebasedupontheappropriate annunciator alarms(allofwhichwereunaffected bytheDCswitchpositions),

orareviewofcontrolboardparameter indications (i.e.RCSpressure, SteamGenerator

pressure, etc.).NACSONMSSSA<~ASI

ISWCiona00SAI043ILICENSEEEVENTREPORTILERITEXTCONTINUATION V.S.IIuCLSASI ASOVLATOIIY COMMISNOII

/ASSAOYlOOM0HO0ISOWIOS%)ttlAllSI314SFACILITYIIAMlIIIOOCIIKTIIUMllAIllLlllMOMOSIII~ISSQMSNTIAL

'SVOIO>MA'MS1R.E.GinnaNuclear~PlantTEXTIFWaOCWOtAteyWet,~ASASOASIIYJICAnti~'SIIITIosooo2449001701090sl5Theeffectofthepotential delayinactuating safeguards equipment uponthose.eventsanalyzedintheUFSARwasevaluated.

Theaccidents effectedbythisactionarethoseaccidents whichresultindepressurization oftheprimarysystemcausingSI.Theseareprimarily thefollowing:

oFeedLineBreak(FLB)oSteamGenerator TubeRupture(SGTR)oSmallBreakLossofCoolantAccident(SBLOCA)oLargeBreakLossofCoolantAccident(LOCA)oSmallSteamLineBreak(SmallSLB)oLargeSteamLineBreak(SLB)Ananalysisoftheseaccidents wasperformed todetermine theeffectofthedisabling ofmanual(pushbutton) andautomatic actuation ofthesafeguards sequenceinitiation withthefollowing results:FeedLineBreakThisaccidentwasanalyzedbytheGinnaUpdatedFinalSafetyAnalysisReport(UFSAR)as'heatupeventwithauxiliary feedwater available inten(10)minutes.Asaheatupevent,RCSpressureneverdecreased belowtheSIsetpoint, butrapidlyincreased abovetheSIpumpshutoffhead.Therefore, SIwasnotnecessary andauxiliary feedwater, whenavailable withinten(10)minutes,issufficient tomitigatetheevent.Operatoractionstostartauxiliary feedwater withinten(10)minutesisconsistent withtheGinnalicensing basis.IftheFLBwasre-evaluated asacooldowneventfrom34powertheresultswouldbeboundedbyaSLB.VAC+0AMSSSA<l00I

MAC4reSSSAITSILICENSEEEVENTREPORTILERITEXTCONTINUATION V.S.IIUCLEAII ASOULATOIIY COMMISNOIe ASSAOVKOOM9kO9ISONICS/SIISIA9$SISI4$SACILITYIIASSSIllOOCIICTIIUMSKRIllLSIIMUM99llISISSQVSNTIAL SVMAA9VISIONMSA~AOSISIR.E.GinnaNuclearPowerPlantTaXTIIT~MMCSe~eeSSA9SAMAIACrenemaSIIITIosooo2449001701100F15SteamGenerator TubeRutureSGTRisboundedbySBLOCAfromtheRCSdepressurization standpoint.

TheleakratefromaSGTRis,smallcomparedtobreakflowforaSBLOCA.Thereisnosignificant effectduetolackofmanual(pushbutton) orautomatic SIsincethemainstepsintheprocedure dealwithisolation oftherupturedSG,depressurization oftheRCS,andtermination ofSI.SmallBreakLossofCoolantAccidentWhenmanual(pushbutton) andautomatic SIwasde-activated, thereactorwasoperating at34power.Thereactorhadbeenat34powerforapproximately ten(10)hours.Priortothat,thereactorhadbeensubcritical fortwenty-two (22)hoursfollowing atrip.Westinghouse Owner'sGroupletterWOG90-113,datedJuly2,1990,"Shutdown LOCAProgram-DraftReport",evaluated amode4LOCAusingagenerictwo(2)loopplantwithasix(6)inchbreakassumedtooccurtwoandahalf(2.5)hoursaftershutdown.

Acceptable resultswereobtainedprovidedSIwasstartedten(10)minutesafterthebreak.Assumptions ofthemode4LOCAanalysis'arecomparedwiththeGinnaEventconditions below:WOGMODE4GINNAEVENTDecayHeat1.34Noaccumulators available RCSpressure1000psigRCStemperature 425oFDecayHeat0.534Accumulators available RCSpressure2235psigRCStemperature 547FTheavailability ofaccumulators andthelowerdecayheatoffsetthehigherRCStemperature andpressure.

Sufficient timeisavailable tomanuallystarttheSIandRHRpumpsandopenappropriate valvesfromtheControlRoom,andtorecoverfromtheSBLOCA.Inanycase,SBLOCAisboundedbyLOCAbecauselesstimeisavailable foroperatoractionduringaLargeBreakLOCA.Nocreditwastakenforchargingflowwhichbyitselfcouldhaveremovedapproximately thatlevelofdecay~heat.

VACSCAMSSSAi9All

NNCfor>>SSSA(S4SIICENSEE EVENTREPORTILERITEXTCONTINUATION U.S.NUCLlAN1SOULATOIIY COMMISSION Aff1OVSOOMSNOSISO&I04/tllfl1SS'SISI4SfACILITYNAMSIIIOOCKSTNUMSSII11ILt1NUMSSNISISSQUSNTIAL ASVISIONNUM1INM~A~AOSQIR.E.GinnaNuclearPowerPlantTSICTIN'a>>Ce>>>>SVfff.

vlfOS>>SOANlVACfWse~VIIITIosooo24490Ol70111OF15LareBreakLossofCoolantAccidentAnassessment ofdisabling manual(pushbutton) andautomatic SIat34powerwasperformed byWestinghouse withrespecttotheLOCAanalysis.

Theassessment assumedtheRCSwasat547F,2235psig.Thefuelrodswereassumedtobeat600Fwhichwouldbetheapproximate pelletandcladtemperature attheend-of-blowdown phase.Thevessellowerplenumandthelowerportionofthecorewouldbecoveredwithaccumulator water.Further,itwasassumedthat,SImustbeinitiated whenthefuelrodsareat1800Ftoturnaroundthecladdingtemperature beforeitreaches2200F.Decayheatisbasedonanapproximation ofpowerhistorypriortotheevent,usingthe1971ANSModel.Anadiabatic heatupcalculation wasperformed usingproperties fora14x14arrayOptimumFuelAssembly(OFA).Thecalculation indicated SIwasnecessary inapproximately 14minutes.Simulations ontheGinnaspecificsimulator indicatealessthan2minuteoperatorresponseduringaLOCAisachievable.

SmallSteamLineBreakThisaccidentisboundedbytheLargeSLBbecauselongertimesareavailable foroperatorresponse.

LareSteamLineBreakWestinghouse assessedtheeffectofnomanual(pushbutton) orautomatic SIontheSteamLineBreakanalysis.

Basedontheirexperiences withSteamLineBreakanalysisaswellasareviewoftheavailable margintotheacceptance

criteria, itwasjudgedthatiftheaccidentwerere-analyzedat34powerwithnomanual(pushbutton) orautomatic SI,acceptable resultswouldbeobtained.

41CfOAQSSSAiSASI

MACSons$$$A1$4$1LICENSEEEVENTREPORTII.ERITEXTCONTINUATION V.$.HUCL$AIIATOULATOIIY COMMI$$IOMASSAOVKOOUIIIO$I$0MIOO$)IOIA$$l/$1/8$SACILITYIIAM$111RoE.GinnaNuclearPowerPlantTSITIII'ssooMMo~nooooY.oMooMMMMAtACASM~$IIITIOOCII$TIIUSM$%11Iosooo244LtllIIVMO$111$l$$CUonTIALsovlslon~IVMS'M~S9001701SAO$1$1120~15Rochester GasandElectricCorporation (RG&E)performed acomputeranalysisoftheSLBusingtheWestinghouse LOFTRANCode.AbasecasewascomparedtoacasewhereSIwasdelayedforten(10)minutes.Thecomparison indicated negligible changeinminimumDNBR.Therewasaninsigni-ficantchangeinmassreleasedtocontainment becausemassreleaseisdominated byinitialsteamgenerator levelandauxiliary feedwater flow,neitherofwhichareaffectedbydelayedSI.Comparing energyoutthebreakforbothcases,showednegligible differences.

Therefore, delayingSIhasnegligible effectonminimumDNBRandmass/energy outthebreak.Inconclusion, delayofmanual(pushbutton) andautomatic SIwiththereactorat34powerwouldnotcauseNon-LOCAeventstoexceedtheacceptance criteria.

Adelayofapproximately 14'inutes intheLOCAcanbetolerated withoutunacceptable results.Basedonoperatortraining, thisissufficient timeforoperatorresponse.

Basedontheabove,itcanbeconcluded thatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVE ACTIONACTIONTAKENTORE'ZURNAFFECTEDSYSTEMSTOPRE-~9FZNORMALSTATUS:Theaffectedsystemwasrestoredtonormalwhenthetwo(2)DCswitcheswereclosedtwenty(20)minutesaftertheywereopened.VACSCAM$$$A<0'

IIAC>wwSSSALICENSEEEVENTREPORTILER)TEXTCONTINUATION V.S.IIUCLSAII IISOULATOIIY COMMISSIOII ASSAOYSOOMSIIO)ISO&I04/SXrlASSSISIISSSACILITYIIAMSIIIOOCIISTIIVMSSIIISILSIIIIUMS~IIISISLOMINTIAL lllVISIQN

~I4144~AOSISIR.E.GinnaNuclearPowerPlantosooo244900170113OF15B.ACT?ONTAKENORPLANNEDTOPREVENTRECURRENCE:

ShortTermActions00SeniorManagement metwithkeyplantpersonnel tocommunicate management expecta-tionsforaquestioning attitudeandattention todetail.Thesegroupsincludedalltheoperating shifts,theMaintenance planningstaff,andPORCmembers.Policieswereissuedaddressing theOpera-tionsShiftSupervisor reviewofprocedures priortogivingauthorization toproceed,andtheMaintenance planners'esponsi-bilitiesforWorkPackagereview.0Allplantprocedures werescreenedforpossibleoperational impactinadequacies, andpotentially deficient procedures weremadeunavailable foruse.Procedures thatweremadeunavailable foruse,butwereimmediately requiredforsafeplantoperation, werecarefully reviewedpriortobeingmadeavailable foruse.AHumanPerformanceEnhancement System(HPES)evaluation wasperformed onControlRoomactivities

'associated withthisevent,toidentifytheneedforanyadditional shorttermcorrective actions.Additional actionswereidentified.

Actionsidentified bytheHPESprocesswereimplemented whereappropriate, including additional upgradesofswitchlabels,amoredetailedreviewofAlarmResponseprocedures, improvedwordingofpro'cedural stepsforHumanFactorsconcerns, andadditional information tobemadeavailable totheoperators.

Forallinvolvedoperations personnel, theiroperating experience andtraininghistories werereviewedforadequacy.

SACAOAMSSSA(0ASI

NACro<<MEEEAI04)IrACILITYNAMEIllUCENSEEEVENTREPORTILER)TEXTCONTINUATION DOCKETNVMEEAIEIVS.NVCLEAIIAEOVLATOIIY COMMIEEION ArrROVEOOMENO3150&104E)IrIAEEEI31/8$~ACEIEI\R.E.GinnaNuclearPowerPlantTExTIh'rrrrNMrr<<Mrr<<EE.<<rEaaseowNOMICfond~'rIIITILEIINVMEEII(EI<<EAASECVENTIAL AEVISIQNNMEAosooo24490017014OF10Anindependent assessment ofthestatusofshorttermactions,andoftheprocedure screening, wasconducted beforemanagement authorized restartofthereactor.2~LongTermActions0AnHPESevaluation oftheprocedure changeprocessisbeingperformed.

Fromthisevaluation, recommendations forlongtermimprovements willbeimplemented.

Amongtheseimprovements aretheincreased involvement ofOperations inthereviewofproposedchanges,requirements formoreaccuratedescriptions ofproposedchanges,andmorerigorinthereviewofchangesatPORCmeetings.

0Toensuretheeffectiveness oftheshorttermcorrective actions,follow-up evalua-tionswillbeconducted.

Basedontheseevaluations, management willdetermine theneedforadditional reinforcement oftheseactions.0ThetrainingprogramsforOperations personnel, PORCmembers,andMaintenance plannerswillbere-evaluated.

Weexpecttomakelongtermimprovements intheseprograms, andinthecontentoftheseprograms, and-alsointhetrainingprogramsforotherplantpersonnel.

0Procedures thatarecurrently unavailable forusewillbereviewedindetailpriortoreleaseforuse.Weareexpediting thereviewofthoseprocedures, placinghighestpriorityonthoseprocedures whichareexpectedtobeneededduringthecourseofroutineoperations, toensuretheiravail-abilityinthenearfuture.NACrOAMEEEA>EATI 0l IIACtoreSSSAIS43IL'ICENSEE EVENTREPORT(LER)TEXTCONTINUATlON V.S.IIUCLEAAAEOULATOIIY COMMITSIOII ANNAOVEOOMSHO)ISO&IONrEXNIAES>II5145NACILITYIIAMEIIIR.E.GinnaNuclearPowerPlantTEXTIN'4eCeeteerrC~NcMOoeVIVJICAwe~1IIITIOOCKKTIIUMItllI1Iosooo244LEIIIIUMOEXINSNOUNHTIAL iNSVOION4VM8HMNi9001701~AOEIll50rl50Policiesthatwereinitiated asaresultofthiseventwillbereviewedforconsistency withpre-existing policiesandprocedures.

whereappropriate, existingpolicieswillbealtered,superseding thenewpolicies.

ADDXTXONAL XNFORMATXON A.FAILEDCOMPONENTS:

None.B.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistorical searchwasconducted withthefollowing results:Nodocumentation ofsimilarLEReventswiththesamerootcauseatGinnaStationcouldbeidentified.

C.SPECXALCOMMENTSNone.VACNOAMSSSAiSOJI 0I

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