ML17263A511

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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

ACCELERATED DISTRIBUTION DEMONSTRATION SYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESSION NBR:9401110017 DOC.DATE:

93/12/22NOTARIZED:

NOFACIL:50-244 RobertEmmetGinnaNuclearPlant,Unit1,Rochester GAUTH.'AME AUTHORAFFILIATION MARTIN,J.T.

Rochester Gas&ElectricCorp.MECREDY,R.C.,

Rochester Gas&ElectricCorp.RECIP.NAME RECIPIENT AFFILIATION DOCKET05000244R'OHNSON,A.R.

ProjectDirectorate I-3

SUBJECT:

LER93-007-00:on 931122,RT occurredduetohighsourcerangefluxlevelduringreactorstartup.Caused byfailureofpersonnel focusingonRTsetpoint.Replaced statuslights&corrected PPCSalarmmessage.W/931222 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR ENCLSIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.ID',$RECIPIENT IDCODE/NAME PD1-3LAJOHNSON,A COPIESLTTRENCL1111RECIPIENT IDCODE/NAME PD1-3PDCOPIESLTTRENCL11NOTES:License Expdateinaccordance with10CFR2,2.109(9/19/72).

A05000244DD,INTERNAL:

AEOD/DOAAEOD/ROAB/DSP NRR/DE/EMEB NRR/DRCH/HHFB, NRR/DRCH/HOLB NRR/DRSS/PRPB NRR/DSSA/SRXB RES/DSIR/EIB EXTERNALEG&GBRYCEgJ~HNRCPDRNSICPOORE,W.112211111122111122.1111AEOD/DSP/TPAB NRR/DE/EELB NRR/DORS/OEAB NRR/DRCH/HI CBNRR/DRIL/RPEB QB~RDSSQ/D PLBLSTLOBBYWARDNSICMURPHYgG~ANUDOCSFULLTXT1111111111111111111111DNOTETOALL"RIDS"RECIPIENTS:

PLEASEHELPUSTOREDUCElVASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOiblPI-37(EXT.20079)TOELIiVIINATE YOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!DDS-FULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:

LTTR28ENCL28

ROCHESTER GASANDELECTRICCORPORATION eR6BERTC,MEGREOYVicePresiden<

CinnaNuclearProduriion rionK.ssssr89EASTAVENUE,ROCHESTER N.Y.14649-0001 TELEPHONE AsrEACODE7165462700December22,1993U.S.NuclearRegulatory Commission Attn:AllenR.JohnsonProjectDirectorate I-3DocumentControlDeskWashington, DC20555

Subject:

LER93-007,HighSourceRangeFluxLevelDuringReactorStartupCausesaReactorTripR.E.GinnaNuclearPowerPlantDocketNo.50-244item(a2ivInaccordance with10CFR50.73LicenseeEvtRt)()(zv),who.chrequiresareportof,"anyeventor~IeneporSystem,condition thatresultedinamanualorautomatic ctt'aeyfeature(ESF),including thereactorprotection system(RPS)",theattachedLicenseeEventReportLER93-007herebysubmitted.

071sThxseventhasinnowayaffectedthepublic'shealthandsafety.Verytrulyyours,RobertC.MecredyXCU.S.NuclearRegulatory Commission RegionI475Allendale RoadKingofPrussia,PA19406GinnaUSNRCSeniorResidentInspector 060053.9401>~OOX7 93>~~>PDRADQCK050002POR

NRCFORH366(5-92)U.S.II)CLEARREGULATORY C<NNIISSION APPROVEDBYQGINO.3150-0104 EXPIRES5/31/95LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/characters foreachblock)ESTIMATED BURDENPERRESPONSETOCOMPLYlllTHTHISINFORMATION COLLECTION REQUEST:50.0HRS.FORHARDCOMMENTSREGARDIHG BURDENESTIMATETOTHEIHFORHATIOH ANDRECORDSMANAGEHENT BRANCH(HNBB7714),U.S.NUCLEARREGULATORY COMHISSIOH, NASHINGTOH, DC20555-0001 ANDTOTHEPAPERUORK REDUCTION PROJECT(31/0-0104),

OFFICEOFMAHAGEHENT ANDBUDGETNASHINGTON DC20503-FAclLITYlQ%(1)R.E~GinnaNuclearPowerPlantDOCKETNQIBER(2)=05000244 PAGE(3)1OF7TITLE(4)HighSourceRangeFluxLevelDuringReactorStartupCausesaReactorTripEVENTDATE5LERINNBER6REPORTDATE7OTHERFACILITIES INVOLVED8MONTHDAY1122YEAR93YEAR93SEQUENTIAL HUHBER--007--REVISIONNUMBER00MOHTH12,DAY22FACILITYNAHEYEARFACILITYHAMEDOCKETNUMBERDOCKETNUMBERSTRAYINGINXIE,(9)

POUERLEVEL(10)N000THISREPORTISSUBMITTED PURSUANT20.402(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,HRCForm366ATOTHEREQUIREMENTS OF10CFR:Checkoneormore11LICENSEECONTACTFORTHISLER12HAMEJohnT~St.Hartin-Director, Operating Experience TELEPHONE NUMBER(IncludeAreaCode)(315)524-4446C<NPLETEONELINEFOREACHC<NPONENT FAILUREDESCRIBED INTHISREPORT13CAUSESYSTEHCOHPOHEHT HANUFACTURER REPORTABLE TONPRDS%%)3%@i4jgc0pQWp:

CAUSESYSTEHCOMPOHEHT HANUFACTURER REPORTABLE TONPRDSSUPPLEMENTAL REPORTEXPECTED14YES(Ifyes,completeEXPECTEDSUBHISSIOH DATE).XEXPECTEDSUBMISSION DATE(15)MONTHDAYYEARABSTRACT(Limitto1400spaces,i.e.,approximately 15single-spaced typewritten tines)(16)Theplantwasathotshutdowncondition, withareactorstartup-inprogress.

At0644ESTthereactortrippedonHighSourceRangeFluxLevel(>/=lE5countspersecond).Theunderlying causewasdetermined tobeaControlRoomoperatornotadeguately focusedonapproaching thereactortripsetpoint.

Withtwostatuslightsburnedoutandamisleading PPCSalarmmessage,theoperatorwasfocusedonPermissive P-6setpointinsteadofthereactortripsetpoint.

(ThiseventisNUREG-1220 (A)causecode.)Corrective actionsweretoreplacethestatuslights,correctthePPCSalarmmessage,andapprisetheControlRoomoperators oftheneedtofocusonreactortripsetpoints.

Corrective actiontoprecluderepetition isoutlinedinSectionV(B).NRCFORH366(5-92)

I NRCFORH366A(5-92)U.SIN)CLEARREGULATORY COIIISSIQILICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBYQQNO.3150-0104 EXPIRES5/31/95ESTIHATED BURDENPERRESPONSETOCONPLYllITHTHISIHFORNATIOH COLLECTIOH REQUEST:50.0HRS.FORlIARDCONNEHTSREGARDIHG BURDENESTIHATETOTHEINFORHATION ANDRECORDSHANAGEHENT BRANCH(NHBB7714),U.S.NUCLEARREGULATORY COHHISSIOHg llASHIHGTON, DC20555-0001 ANDTOTHEPAPERlSRK REDUCTIOH PROJECT(3140-0104),

OFFICEOFHANAGENENT ANDBUDGETMASHINGTON DC20503.FACILITYNAHE1R.E.GinnaNuclearPowerPlantDOCKETN(NBER2YEAR05000244'3 LERNIMBER6SEOUEHTIAL

--007-REVISION00PAGE32OF7TEXT(Ifmorespaceisrequired, useadditional copiesofHRCForm366A)(17)PRE-EVENT PLANTCONDITIONS Theplantwasstableinthehotshutdowncondition, andthereactorwassubcritical withareactorstartupinprogress, usingprocedure 0-1.2(PlantStartupFromHotShutdowntoFullLoad).II.DESCRIPTION OFEVENTA.DATESANDAPPROXIMATE TIMESOFMAJOROCCURRENCES:

oNovember22,1993,0644EST:Eventdateandtime.oNovember22,1993,0644EST:Discovery dateandt'ime.oNovember22,1993,0644EST:ControlRoomoperators verifybothreactortripbreakersopen,andallcontrolandshutdownrodsinserted.

oNovember22,1993,0650EST:Plantstabilized athotshutdowncondition.

B.EVENT:Atapproximately 0643EST,theControlRoomoperators wereconducting thefinalapproachtocriticality, inaccordance withprocedure 0-1.2.Theoperatorperforming thereactorstartupwasmovingcontrolrodsouttoestablish apositivestartuprate(SUR)priortodeclaring thereactorcritical.

Atthistime,thetwoNuclearInstrument System(NIS)SourceRange(SR)instruments wereindicating reactorpower.atapproximately 5E4countspersecond(CPS).TheControlRoomoperatorwasanticipating thatPermissive P-6statuslightswouldilluminate atthistime,priortoexceeding thereactortripsetpointof1E5CPS.Permissive P-6setpointisgenerated fromNISIntermediate Range(IR)channels, when1of2channelsisabove1E-10amps.Thisisnormallyequivalent toapproximately 1E4CPSindication ontheSR'instruments.

Permissive P-6allowstheControlRoom,operatortomanuallyblocktheHighSourceRangeFluxLevelreactortripandde-energize theSRdetectors.

NRCFORM366A(5-92)

NRCFORH366A(5-92)U.S.NUCLEARREGULATORY CNHIISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBY(NBNO.3150-0104 EXPIRES5/31/95ESTIHATED BURDENPERRESPONSETOCOHPLYWiTHTHISINFORHATION COLLECTIOH REQUEST:50.0HRS~FORWARDCONHENTSREGARDIHG BURDENESTIHATETOTHEINFORMATION AHDRECORDSHANAGEHEHT BRANCH(HHBB7714),U.S.NUCLEARREGULATORY COHHISSIOH, WASHINGTON, DC205550001AHDTOTHEPAPERWORK REDUCTION PROJECt(3150-0104),

OFFICEOFHANAGEHENT AHDBUDGETWASHINGTON DC20503.FACILITYNAHE1R.E.GinnaNuclearPowerPlantDOCKETNNBER.2YEAR0500024493LERNNBER6SEQUEHTIAL-007--REVISION00PAGE33OF7TEXT(Ifmorespaceisrequired, useadditionat copiesofHRCForm366A)(17)PriortotheP-6statuslightsilluminating, atapproximately 0644EST,thereactortrippedonHighSourceRangeFluxLevel()/=1E5CPS).TheControlRoomoperators performed theappropriate actionsofEmergency Operating Procedure E-0(ReactorTriporSafetyInjection),

andverifiedthatsafetyinjection wasnotactuatedorrequired.

Theythentransitioned toEmergency Operating Procedure ES-0.1(ReactorTripResponse).

The-plantwassubsequently stabilized inhotshutdown, usingprocedure 0-2.1(NormalShutdown'to HotShutdown).

C~INOPERABLE STRUCTURES gCOMPONENTS

/ORSYSTEMSTHATCONTRIBUTEDTOTHEEVENT:oThelightbulbsforthestatuslightsthatprovideindication thatreactorpowerisabovePermissive P-6werebothburnedout.oPlantProcessComputerSystem(PPCS)alarmmessagetoindicatereactorpowerisabovePermissive P-6wasmisleading.

WithreactorpowerabovetheP-6setpoint, thePPCSalarmmessageindicated thatpowerwasstillbelowthesetpoint.

D.OTHERSYSTEMSORSECONDARY FUNCTIONS AFFECTED:

NoneE.METHODOFDISCOVERY:

Thiseventwasimmediately apparentduetoMainControlBoardAnnunciator D-26(SourceRangeHiFluxLevelReactorTriplE5CPS)andotheralarmsandindications intheControlRoom.HRCFORH366A(592)

II NRCFORH366A(5-92)U.S.INCLEARREGULATORY CONISSIONAPPROVEDBY(NQNO.3150-0104 EXPIRES5/31/95LICENSEEEVENTREPORT(LER)TEXTCONTINUATION ESTIHATED BURDENPERRESPOHSETOCOHPLYMITHTHISINFORHATION COLLECTIOH REOUEST:50.0HRS.FORMARDCOHHEH'IS REGARDING BURDENESTIHATETOTHEIHFORHATIOH ANDRECORDSHANAGEHEHT BRANCH(HNBB7714),U.S.NUCLEARREGULATORY,COHHISSION, MASHINGTOH, DC20555-0001 ANDTOTHEPAPERNNKREDUCTION PROJECT(3'I40-0104),

OFFICEOFHANAGEHENT ANDBUDGETMASHINGTON DC20503.FACILITYlOWE1R.E.GinnaNuclearPowerPlantDOCKETNNIBER2YEAR0500024493LERNINBER6SEOUENTIAL

-007--REVISION00PAGE34OF7TEXT(Ifmorespaceisrequired, useadditional copiesofHRCForm366A)(17)F.OPERATORACTION:Afterthereactortrip,theControlRoomoperators performed theappropriate actionsofEmergency Operating Procedures E-0(ReactorTriporSafetyInjection) andES-0.1(ReactorTripResponse).

Theplantwasstabilized athotshutdown.

Subsequently, theControlRoomoperators notifiedhighersupervision.

TheNuclearRegulatory Commission wasnotifiedper10CFR50.72, Non-Emergency, 4HourNotification atapproximately 1022EST.G.SAFETYSYSTEMRESPONSES:

NoneIII.CAUSEOFEVENTA.IMMEDIATE CAUSE:ThereactortripwasduetoNISSRhighfluxlevelabovetheSRreactortripsetpointof1E5CPS.B.INTERMEDIATE CAUSE:ThehighfluxlevelwascausedbyfailuretoblocktheSRreactortrip,afterestablishing aSURofapproximately 0.5to1decadesperminute(DPM)duringthefinalapproachtocriticality, withpowerapproaching theSRreactortripsetpoint.

NRCFORH366A(5-92)

NRCFORM366A(5-92)U.S.NUCLEARREGULATORY COHISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBY0$NO.3150-0104 EXPIRES5/31/95ESTIMATED BURDEHPERRESPOHSETOCOMPLYMITHTHISIHFORHATIOH COLLECTIONREQUEST:50.0"HRS.FORMARDCOMMENTSREGARDIHGBURDENESTIMATETOTHEINFORHATIONANDRECORDSMANAGEHEHT BRANCH(HHBB7714),U.S.NUCLEARREGULATORY CDMHISSIOH

~MASHINGTOH, DC20555-0001 AHDTOTHEPAPERNORK REDUCTION PROJECT(31i0-0104),

OFFICEOFMANAGEMENT ANDBUDGETMASHINGTON DC20503.FACILITYNAME1R.E.GinnaNuclearPowerPlantDOCKETIRHIBER205000244YEAR93-007--00LERMINBER6SEQUENTIALREVISIONPAGE35OF7TEXT(Ifmorespaceisrequired, useadditional copiesofHRCForm366A)(17)C.ROOTCAUSE:Theunderlying causeofthefailuretoblocktheSRreactortripwithpowerincreasing ata0.5to1DPMSUR,wascognitive personnel errorbyaControlRoomoperator.

TheControlRoomoperatorwasnotadequately focusedonapproaching theSR.reactortripsetpoint.

TheControlRoomoperatorwasanticipating thatthestatuslightsindicating reactorpowerabovePermissive P-6setpointwouldbeilluminated, allowingblockoftheSR-reactor trip,priortoreachingthetripsetpoint.

Hisattention wasfocusedonthesestatuslightsinsteadofontheapproachtothereactortripsetpoint.

Thestatuslightsdidnotilluminate duetothelightbulbsbeingburnedout.ThePPCSalarmmessageprovidedincorrect reinforcement thatreactorpowerwasstillbelowtheP-6setpoint.

Theactionsoftheoperatorperforming thereactorstartupwerenotcontrarytoprocedures established forthisevolution.

(ThiseventisNUREG-1220 (A)causecode,Personnel Error.)IV.ANALYSISOFEVENTThiseventisreportable inaccordance with10CFR50.73,LicenseeEventReportSystem,item(a)(2)(iv),whichrequiresareportof,"anyeventorcondition thatresultedinmanualorautomatic actuation ofanyengineered safetyfeature(ESF)including thereactorprotection system(RPS)".Thereactortripwasanautomatic actuation oftheRPS.Anassessment wasperformed considering boththesafetyconsequences andimplications ofthiseventwiththefollowing

~resultsandconclusions:

Therewerenosafetyconsequences orimplications attributed tothereactortripbecause:oThetworeactortripbreakersopenedasrequired.

oAllcontrolandshutdownrodsinsertedas=-designed.

/oTheplantwasstabilized athotshutdown.

HRCFORM366A(5-92)

NRCFORH366A(5-92)U.S.IR)CLEARREGULATORY CQIIISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBYQGINO.3150-0104 EXPIRES5/31/95ESTIHATED BURDEHPERRESPONSETOCOHPLYMITHTHISIHFORHATIOH COLLECTIOH REQUEST:50.0HRS.FORllARDCOHHEHTSREGARDIHG BURDENESTIHATETOTHEIHFORHATIOH ANDRECORDSHANAGEHEHT BRANCH(HHBB7714),U.S.NUCLEARREGULATORY COHHISSIOH,

'WASHINGTON, DC20555-0001 AHDTOTHEPAPERIQRK REDUCTION PROJECT(3140-0104),

OFFICEOFHAHAGEHEHT AHDBUDGETNASHIHGTOH DC20503.FACILITYNAHE1DOCKETNIMBER2LERNLSIBER6SEQUENTIAL REVISIOHPAGE3R.E.GinnaNuclearPowerPlant'500024493"-007--00'OF7TEXT(lfmorespaceisrequired, useadditional copiesofHRCForm366A)(Tl)Thereactortripdidnotcauseanyreactorcoolantsystem(RCS)transient, asthere'actorwasnotatthepointofaddingheat.Allreactorprotection circuitry actuatedasdesignedtoplacethereactorinatrippedmodeathotshutdown.

Basedontheaboveandareviewofposttripdataandpastplanttransients, itcanbeconcluded thattheplantoperatedasdesignedandthat*therewerenounreviewed safetyquestions andthatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVE ACTIONA.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENT NORMALSTATUS:oThelightbulbsforthestatuslightsthatindicatereactorpowerisaboveP-6werereplaced, andasurveillance procedure wasperformed toverifytheirfunctionality.

oThePPCSalarmmessageforP-6wascorrected toensureaclearunderstanding ofthestatusofPermissive P-6.0Operations Management reevaluated theirexpectations foranappropriate approachtocriticality atfluxlevelsneartheSRreactortripsetpoint, andcommunicated theserevisedexpectations tothepersonnel ontheOperating Shiftscheduled toperformthesubsequent reactorstartup.B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:

,0Procedure 0-1.2wasrevisedtoincorporate therevisedmanagement expectations.

Theseincludedprocedural guidancefor(1)aconservative powerlevel(belowtheSRreactortripsetpoint),

wherethepowerincreaseshouldbestoppedtoevaluatethestatusofP-6,ifP-6statuslightshavenotilluminated, (2)aconservative SURwhentheSRreactortripsetpointisnotdefeated, (3)aformalized shiftbriefingconducted bytheShiftSupervisor, priortocommencing areactorstartup.NRCFORH366A(5-92)

NRCFORH366A(5-92)U.SNICLEARREGULATORY COHISSIOH LICENSEEEVENTREPORT(LER)TEXTCONTINUATION NAPPROVEDBYQHINO.3150-0104 EXPIRES5/31/95ESTIHATEDBURDENPERRESPONSETOCONPLYillTHTHISINFORHATIONCOLLECTIONREQUEST:50.0HRS~FORllARDCONHENTSREGARDIHGBURDENESTINATETOTHEINFORHATIONAHDRECORDSHANAGEHEHT BRAHCH(HHBB7714),U.S.NUCLEARREGULATORY CONHISSIOHg MASHIHGTOH, DC20555-0001 AHDTOTHEPAPERMORK REDUCTION PROJECT(3140-0104),

OFFICEOFHANAGENENT ANDBUDGETNASHIHGTON DC20503.FACILITYl6WE1R.E.GinnaNuclearPowerPlantDOCKETNl(BER20500024493-007--00LERNNBER6YEARSEQUENTIAL REVISIONPAGE37OF7TEXT(lfmorespace00isrequired, useadditional copiesofHRCForm366A)(17)Personnel ontheOperating Shiftscheduled toperformthesubsequent reactorstartupweretrainedontherevisions toprocedure 0-1.2priortocommencing thestartup.AHumanPerformance Enhancement System(HPES)evaluation wasperformed todetermine causalfactorsforthisevent.The.resultsoftheHPESevaluation wereusedtoidentifytherootcauseandappropriate corrective actions.0ThetwoControlRoomoperators directlyinvolvedinthis.reactortripwereremovedfromshiftuntiltheyhadcompleted additional simulator trainingonreactorstartups, andhadbeenapprisedoftherevisedmanagement expectations contained intherevisiontoprocedure 0-1.2.00All.licensed reactoroperators, aspartofnormaltraining, willbetrainedontherevisions toprocedure 0-1.2.Appropriate lessonplansfortheLicensedOperatorTrainingprogramswillberevisedtoensuremanagement expectations contained inprocedure 0-1.2arecontinually reinforced duringsimulator training.

VI.ADDITIONAL INFORMATION A.FAILEDCOMPONENTS:

NoneB.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistorical

.searchwasconducted withthefollowing results:Nodocumentation ofsimilarLEReventswiththesamerootcauseatGinnaNuclearPowerPlantcouldbeidentified.

C.SPECIALCOMMENTS:

NoneHRCFORN366A(5-92) 7