Analysis of Reactivity Management Events

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WANO REPORT
RPT ǀ 2015-6 July 2015

Analysis of Reactivity Management Events
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Report ǀ RPT 2015-6

Revision History
Author Date Reviewer Approval
Arshad Mahmood 24 July 2015 Michael Ballard Jo Byttebier
Reason for Changes:
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REPORT ǀ RPT 2015-6

CONTENTS
Analysis of Reactivity Management Events 2
Purpose 2
Analysis Methodology 2
Executive Summary 2
Summary of consequential reactivity management events 3
Summary of actions taken by plants in response to events reported to WANO 5
Specific observations from WANO PR AFIs 6
SOER 2007-1 Recommendation Implementation Status 8
References 9
Attachment 1 10
Analysis of the OE Events 10
Attachment 2 15
SOER 2007-1 Rev 1 Recommendations 15
Attachment 3 18
List of Reactivity Management Related Events Reported to WANO 18
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Purpose
This report discusses and informs WANO members of recent significant and consequential reactivity
management events including key lessons learned that if used, can help prevent similar events in the
future. The report is based on the following sources:
• Analysis of approximately 120 reactivity management-related events that were reported to WANO
from January 2013 to March 2015.
• Areas for improvement (AFIs) during 2013 and 2014 WANO Peer Reviews (PR).
• Current implementation status of the SOER 2007-1 Rev 1, Reactivity Management recommendations
(reference 1).
This analysis was also initiated to evaluate whether the current WANO documents and actions on reactivity
management are sufficient to address related weaknesses at member power plants. From reference 2, the
definition is the following:
Reactivity management relates to the operating philosophy and specific guidance applied to controlling
conditions that affect reactivity. This includes all activities that ensure core reactivity and stored nuclear
fuel (where the potential for criticality can occur) are monitored and controlled consistent with fuel design
and operating limits. It is a key factor in ensuring integrity of barriers to fission product release.
Analysis Methodology
The analysis period of 27 months (January 2013 to March 2015) was selected to have a sufficient number of
events to attain a meaningful analysis. Approximately 120 reactivity management-related events were
analysed for direct and root causes, lessons learned, and corrective actions.
WANO Peer Review reports from 2013 and 2014 were reviewed to identify AFIs related to reactivity
management weaknesses.
The implementation status of the SOER 2007-1 Rev 1, Reactivity Management recommendations was also
reviewed.
Executive Summary
There are a substantial number of reactivity management related events reported to WANO. Ten (8%) of
the 120 selected events were classified as Significant or Noteworthy by WANO due to their consequences.
Some events could have been prevented by effectively applying the guidance in SOER 2007-1 Rev 1. While
the SOER was published in 2007, many plants still have not satisfactorily implemented all the
recommendations. Thorough review and timely implementation of these recommendations is necessary.
Strong reactivity management is essential for maintaining nuclear safety. Leaders at member stations must
provide additional direction and oversight to ensure industry operating experience is used to prevent
reactivity management events. Some actions to consider include the following:
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• Conduct a reactivity management self-assessment against the guidance in SOER 2007-1 Rev 1, and GL
2005-03 Rev 1, Guidelines for Effective Reactivity Management. Using these documents as references,
assess programmes, processes, training, and operator and reactor engineering performance to ensure
the aspects of the original recommendations are implemented to prevent operator-induced reactivity
management events. Implement corrective actions as appropriate. (Note that recommendation 6 of
SOER 2007 Rev 1 states to conduct a self-assessment. If this assessment was not completed, members
should conduct one as soon as possible. If an assessment was previously conducted, reassess to ensure
it was comprehensive and reflects current operating practices.)
• Align all personnel and reinforce the need to be intolerant of human errors and critical equipment
problems that can adversely affect reactivity management. High priority should be placed on timely
resolution of related issues.
• Several consequential reactivity management events were caused by degraded equipment due to
ageing in non-safety related control systems. These systems may provide reactor or balance of plant
control (for example, main turbine or feedwater control). Since the systems are non-safety related,
they may lack redundancy. System upgrades to add redundancy to these single point vulnerabilities
are expensive and may be difficult to justify for an older power plant. Some stations use the
equipment reliability model described in AP-913 (reference 3) to classify components as critical,
noncritical, and run-to-failure. Components that can affect reactivity would most likely be classified as
critical and require a preventive strategy and long-term plan to manage ageing.
• Several events occurred during low power operation when operators did not effectively manage
reactivity changes, demonstrated knowledge weaknesses, and did not understand the risks of the
inappropriate actions taken that caused the events. The problems revealed during recent events may
be indicative of operational gaps in nuclear safety culture; particularly taking personal responsibility
and accountability for nuclear safety.
Summary of consequential reactivity management events
Reactivity Management Events Related to Gaps in Human Performance
The following events are examples of weaknesses in operator knowledge, supervisory oversight, teamwork,
risk recognition or use of human error reduction tools (including self checking, procedure adherence, peer
checking and others). The events directly relate to the SOER 2007-1 Rev 1 recommendations 1, 2 and 4 and
guidance in GL 2005-03 Rev 1. These documents remain applicable to current events and revision is not
deemed necessary.
• While transferring turbine controls from full to partial arc mode during power ascension after a forced
outage, an unplanned 147 MW load increase occurred over approximately four and a half minutes.
This event is significant because there was an unplanned increase in reactor power of about 11%
because of procedural deficiencies compounded by a lack of questioning attitude and non-
conservative decision making. In response, control rods in bank D groups one and two automatically
withdrew to full out (all rods were fully withdrawn from the core). Reactor power rose from 77.5% to
88.3% over approximately six minutes. An investigation following the event determined that the crew
performed the transfer while in open loop mode, which is not one of the two acceptable modes. In
addition, the transfer was performed at a power level which was higher than that recommended by
the vendor. Vendor guidance on the mode of operation or power level at which to perform the
transfer was not included in the applicable procedure. Design configuration controls did not validate
functional aspects and operator interfaces associated with changing arc admission mode. (WER ATL
13-0542)
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• During power ascension, reactivity was not controlled effectively by operators following a turbine trip
without reactor scram. This event is noteworthy because of the risk of uncontrolled criticality. The
cause of the reactivity event was operator error for not using procedures appropriately and lack of
questioning attitude. The turbine tripped from 37% power because of a high-level condition in the
moisture separator reheater drain tank. The high-level condition was false due to degraded
instrumentation. During the transient, the grey control rods went below the very low insertion limit
and the reactor became subcritical. With the intention to limit the primary temperature drop and
reduce the risk of safety injection actuation, the grey control rods were manually withdrawn twice,
instead of reducing the feedwater flow. These actions resulted in inadvertent transition to startup
mode in violation of the technical specifications. (WER PAR 14-0743)
• During shutdown at minimal controlled power, a trainee reactor operator withdrew control rods in
manual mode by mistake instead of inserting them. This event resulted in emergency reactor
protection activation and automatic insertion of control rods on power increase rate. The event is
noteworthy because the transient involved an unplanned increase in core reactivity during shutdown
conditions caused by control rods manipulations by a trainee operator. (WER MOW 14-0143)
• During power ascension following a reactor coolant pump trip, control room operators made two
errors while focused on the reactor power stabilisation affected by the ongoing xenon poisoning as
well as on the preservation of the axial flux difference in a prescribed range. After reaching maximum
xenon poisoning, decay of xenon started adding positive reactivity. First, the operator combined
manual control rod movement with changes of boron concentration using the water makeup system.
Second, the operator performed manual manipulations of one group of control rods while the other
was in automatic control, which led to violation of allowable overlap between the two control rod
groups. This event is noteworthy because two separate activities that added positive reactivity were
occurring simultaneously. (WER MOW 13-0089)
• While shutting down a boiling water reactor for an outage and the reactor subcritical, unexpected
insertion of positive reactivity returned the core to a supercritical state, with a positive period of
approximately 200 seconds. Operators made knowledge-based decisions without involving other team
members. Contributing causes were that the crew lacked proficiency with core response during soft
shutdown and failure of adherence to procedures. This event is significant because the unexpected re-
criticality transient while shutting down. The operators had stopped inserting control rods to perform
the final insertion of the source range monitors (SRM), as these SRMs had only been partially inserted
before contrary to procedural guidance to fully insert the SRMs. The absence of control rod insertion
combined with the positive reactivity from continued plant cooldown and xenon decay resulted in the
reactor core returning to a critical state. (WER ATL 14-0841)
• During hot standby and while testing control rod drop time, an operator erroneously repositioned a
shutdown rod bank at 218 steps instead of the right position of 228 steps. The dilution performed
hereafter violated the requirement not to dilute the reactor coolant system when one of the
shutdown rod banks is not in the right position. The mispositioning was discovered and corrected after
more than 10 hours, resulting in reduced negative reactivity margin in the event of a reactor scram.
(WER PAR 14-0208)
• While advanced gas reactor online refuelling and during control rod maintenance, it was identified
that control plug assembly (CPA) removed from one channel contained a grey type control rod rather
than the black type. Control rod configuration had not been maintained. Refuelling personnel did not
do a visual or physical confirmation of the control rod type when the rod was previously installed. At
the plant, control rods are the primary reactor shutdown system. There are two main types of control
rod, ‘black’ and ‘grey’, which have different negative reactivity worth. Shutdown margin assessments
were immediately carried out and confirmed there had been an adequate margin within technical
specification nuclear safety requirement and limiting condition of operation limits at all times during
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the period of operation with one channel containing a grey rod instead of black. The root cause was
lack of procedural use and adherence. (WER PAR 13-0075)
Reactivity Management Events Related to Gaps in Equipment Performance
• During normal operation, the condensate minimum-flow valve failed and opened, causing a feedwater
flow reduction. Reactor level lowered by five inches causing an unexpected 47 MWt power increase.
The feedwater level control system compensated to return reactor parameters to normal. This event is
noteworthy because it resulted in the reactor exceeding 102% rated power by technical specification.
The cause was the failure of an obsolete minimum valve controller. The controller had an inadequate
post-refurbishment test. A controller replacement project plan had not implemented in timely
manner. (WER ATL 14-1001)
• During normal power operation, a steam generator power-operated relief valve failed open and
thermal power unexpectedly increased. The cause was a controller failure from a dirty potentiometer
associated with the setpoint dial. Oxidation and foreign material had built up on the potentiometer
contacts. There was no periodic maintenance plan in place to clean the potentiometers. (WER ATL 13-
0192)
• During a power manoeuvre for a planned rod pattern adjustment, a reactor recirculation pump speed
lowered inadvertently to minimum and reactor power lowered from 88% to 60%. Single loop
operation was entered for recirculation loop flow mismatch. The recirculation pump controller lower
(speed reduction) pushbutton contacts were found stuck in the closed position. The root causes were
ageing and fatigue of the button. (WER ATL 14-0340)
Summary of actions taken by plants in response to events reported to WANO
Plants that experienced reactivity management events took several corrective actions to avoid recurrence
of these events. Some of these actions are listed below.
1. Self-assessing and improving implementation of the recommendations in SOER 2007-1 Rev 1,

Reactivity Management and SOER 2013-1, Operator Fundamental Weaknesses.
2. Clarifying and reinforcing the standards and expectations for performing reactivity management
related activities, such as adherence to procedures, avoiding any disturbance, peer check or others.
3. Assessing and clarifying the roles of personnel involved in reactivity management related activities:
oversight, peer, reactor engineer and others.
4. Checking and improving quality of existing procedures (correct the errors in the procedures; add
background in procedures based on OE).
5. Promoting deliberate control of all factors and parameters that can affect the reactivity of the core
(operator fundamentals).
6. Reviewing and improving the initial reactor knowledge training for newcomers.
7. Including reactivity management OE events in simulator training.
8. Organising regular or specific re-training sessions for all personnel on basic reactivity management
principles and risks. For example, the risks of executing simultaneously different reactivity changes and
risk of distraction during activities that could impact the reactivity of the core such as boron dilution or
control withdrawal.
9. Conducting specific human error reduction training sessions for operating crews.
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10. Reinforcing the use of appropriate pre-job briefs and Just in Time training before less frequently
performed tasks or evolutions that can affect reactivity. For example, saturating with boron of resins
contained in the demineralisers prior to taking the demineraliser into operation to avoid boron
dilution of the primary system.
11. Prioritising and correcting long-standing equipment issues that can cause reactivity management
events such as internal valve leakage and degraded electrical/electronic equipment (electronic cards
and control rod drives components).
Specific observations from WANO PR AFIs
Human Performance Related AFIs
Similar to the reactivity management events reported to WANO, areas for improvement (AFIs) from recent
WANO peer reviews demonstrate complacency and weaknesses in teamwork, supervisory oversight, and
human error reduction tool usage and procedure adherence. Examples of AFIs include the following:
• Occasionally, operators and reactor engineers are not managing reactivity near the point of criticality
with sensitivity and conservatism. This has resulted in two unit startups in which the reactor
unexpectedly went subcritical after achieving initial criticality and one startup in which plant heat-up
rates were exceeded. A contributing cause was that operating standards were not adequate to
prevent these conditions and establish proper operator response actions if required.
• The conduct of reactivity changes, the response to alarms and parameter monitoring, together with
some behaviours do not meet the intent of some attributes and fall below industry best practices (for
example, see GL 2005-03 Rev 1). This has resulted in personnel distractions during surveillance duty
and could challenge safe operation of the plant.
• Weaknesses in self-checking and procedure use are resulting in plant events. This weakness
contributed to operator errors that have caused a reactor trip and a reactivity event, and led to
dropping of several spent fuel bundles. Contributing, supervisors sometimes do not set and enforce
expectations for error-prevention tool use to influence the outcome of an activity.
• Deficiencies exist in routine reactivity practices such as not using procedures, inadequate use of error
prevention techniques and gaps in team communications. This has resulted in in two unplanned power
increases and an expected power range being exceeded for 35 minutes without correction.
• Important actions linked to reactivity management are conducted without using procedures, without
requesting supervision, and without using human performance tools.
Equipment Performance Problems Contributing to Reactivity Management AFIs
Causes of recent equipment performance AFIs related to reactivity management coincide with those in the
events reported to WANO; such as defective replacement parts, not managing equipment ageing, and
incomplete cause analysis. A strong equipment reliability programme modelled after AP-913 (reference 3)
can be used to close these weaknesses. Examples of recent AFIs include the following:
• Some important components have failed or not met functional requirements because vendor changes
in design and assembly or faulty manufacturing practices were not recognised before installation. The
deficient components have resulted in reactivity equipment issues, outage extension, and an
emergency diesel generator startup failure. Contributing, comprehensive evaluations and appropriate
oversight were lacking during parts procurement.
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• In several cases, age-related failures are occurring on circuit cards and electrical subcomponents in
systems that monitor and control reactivity.
• Multiple challenges exist with a few systems important for plant reliability and reactivity control. The
aggregate impact has resulted in the inability of the turbine plant cooling water system to maintain
adequate cooling and low-level reactivity events because of control issues with the integrated control
system. Contributing are unclear system monitoring and trending and narrow extent-of-condition
evaluations of equipment failures.
• Shortfalls in preventive maintenance strategies for critical relays and important heater drain system
electronic components resulted in critical system failures and operator challenges. Relay failures led to
unavailability of the auxiliary feed water and residual heat removal systems, and level transmitter
failures led to feed water heater level transients that affected reactivity. The lack of a focused relay
programme is delaying implementation of industry guidance.
Management Weaknesses Related AFIs
Recent AFIs related to reactivity management with causes attributed to management shortfalls include the
following:
• Weaknesses in reactivity control and configuration control is not always identified and challenged by
the management team. Management not effectively driving continuous improvements in key safety
performance activities.
• Senior managers have not resolved some deficient conditions in important equipment that can affect
reactivity control. This has resulted in reduced operating margin and has left operating crews without
supplemental direction for these conditions. Contributing to this is that managers do not sufficiently
challenge the organisation to implement comprehensive actions that drive organisational intolerance
of long term and recurring equipment failures.
• Managers and leaders do not always challenge behaviour, reinforce station expectations, or
demonstrate the correct standards. In addition, expectations are not always set or documented. In
some instances, such shortfalls in management have left inappropriate actions or behaviours
unchallenged, in particular regarding fuel integrity and reactivity management.
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SOER 2007-1 Recommendation Implementation Status
SOER 2007-1 Rev 1 recommendations have not been satisfactorily implemented at many stations. While
the SOER was published in 2007, plants in several regional centres have very low percentage of satisfactory
implementation. It is recommended that WANO members carefully review the recommendations and
conduct a reactivity management self-assessment against the guidance in SOER 2007-1 Rev 1 and GL 2005-
03 Rev 1, Guidelines for Effective Reactivity Management. The full definition of each SOER 2007-1
recommendation is provided in Attachment 2.
In 2014, SOER 2007-1 was reviewed during 44 WANO peer reviews. Recommendations 1, 2, and 4 were
evaluated to be not satisfactorily implemented 32%, 27% and 41% respectively.
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References
1. SOER 2007-1 Rev 1, Reactivity Management
2. GL 2005-03 Rev 1, Guidelines for Effective Reactivity Management
3. AP 913 Rev 4, Equipment Reliability Process
4. SOER 2013-1, Operator Fundamental Weaknesses
5. GL 2002-02, Excellence in Human Performance
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Attachment 1
Analysis of the OE Events
This attachment provides an overview of analysis based on selected reactivity management events
submitted to WANO.
1. There is a general increasing trend in reactivity management events over the last two years.
Figure 1 shows the number of reactivity management-related events reported to WANO in the period
from January 2013 to March 2015.
Figure 1 : Reactivity Management Events reported to

WANO
25 23
22
20 19
16
15 13
10 10
10
5 4
3
2. Most events are reported by plants that have been in operation for a longer time.
Figure 2 shows the number of reactivity management-related events in the reported period compared
to the age of the reactor. Reactivity management-related events happen not only in new stations.
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Figure 2: Number of Reactivity Management Events

Compared to the Age of the Reactor
45
40
40
35
Number of Events
30
25 22
18 19
20
15 11
10
5
5 2 2 1
0 0 0
0
0 5 10 15 20 25 30 35 40 45 50 55
Age of Reactor
3. Reactivity management events occur in all modes of plant operation including shutdown, startup, low
power operations, power ascension and full power operations. The largest number happened during
normal operations.
Figure 3 illustrates the reactor status at the time the event occurred.
Figure 3 : Reactor Status at the time of Event

3%
9%
11% normal operation
startup
17% 60% power ascension
shutdown
Power reduction
4. Most reported events are non-consequential or have limited consequences, but are considered as
important precursors of larger events.
The 120 events included in the analysis were classified by WANO using the criteria in the OE reference
manual as follows:
• Significant (2%)
• Noteworthy (7%)
• Trending (76%)
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• Other (15%)
Events are classified as Significant or Noteworthy if there is catastrophic damage to main components,
as well as impairment to nuclear safety functions and significant degradation of ability to control or
monitor reactivity, e.g. reactor power change greater than 2% of rated thermal power or a substantial
loss of production. Reactivity management events with less consequential economical loss or
impairment on safety related components are classified as Trending. Events are classified as Other
when there are minor or no consequences. These criteria are listed in the WANO OE reference
manual.
5. High level contributors to reactivity events are related equipment degradation, human performance
errors and management weaknesses. Human performance related causes are identified in
approximately 50% of the events. Lack of knowledge and insufficient use of human error reduction
tools are the main contributors. Some reactivity transients were the result of control rod
mispositioning and unplanned boron dilution.
Figure 4 shows the distribution of the main causes. Note that for some events it was difficult to
identify only one main cause. Therefore the total number of causes (128) exceeds the number of
events (120).
Figure 4 : Causes of Reactivity Management Events
Human Performance 52
Equipment Performance 58
Management Weaknesses 18
0 10 20 30 40 50 60 70
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Systems involved in Reactivity Management Events
Figure 5 shows which systems were most involved in the reactivity management-related events of the
reported period.
Figure 5 : Systems involved in Reactivity Management Events
7% control rod
8%
32% boron control
8%
reactor recirculation flow
16% liquid zone control

feedwater flow and temperature
14%
8% steam flow and pressure
7%
neutron flux monitoring
others
Control Rod
Control rod mispositioning can have different causes as shown in the examples below:
• Ageing electronic components

• Failing electronic components for other reasons
WER PAR 14-0173
During normal operation, operators could not withdraw control rods due to loss of the data processing
system (DPS). The reactor was manually scrammed because the DPS was not recovered within the required
time, resulting in entry into a limiting condition of operation. The direct cause was a failure of the DPS due
to ageing.
WER ATL 13-0692
During performance of a weekly surveillance activity, a control rod failed, resulting in a power decrease
from 100% to 97%. The power was later lowered to 82% to recover the rod. The cause was failure of a fuse
in the scram solenoid pilot valve circuit.
WER ATL 14-0614
During normal operation and while performing the monthly control element assembly (CEA) free
movement test, a CEA partially dropped. The reactor power was reduced to 96% and a 72 hour limiting
condition for operation was entered. The probable cause was an individual CEA coil power programmer
timer module malfunction.
WER ATL 14-0977
During normal operation, a partial rod drop occurred during a control rod surveillance test. Changes in the
shutdown margin procedure resulted in an unsatisfactory shutdown margin, leading to rapid boration and a
reactor down-power followed by manual scram as required per technical specifications. The direct cause of
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the dropped control rod was a short circuit of the control rod drive mechanism power supply cable. The
apparent cause of the unexpected shutdown margin results was the shutdown margin procedure.
Boron Control
Unplanned or uncontrolled boron dilution can have causes an increase in reactivity. Most boron dilution
events are initiated by human errors including improper actions and inadequate use of procedures. Errors
in maintenance and degradation of equipment also contribute to boron dilution events.
WER ATL 13-0676
While operating at steady power, a mixed bed demineraliser was placed in service for lithium removal from
the reactor coolant system, which resulted in a decrease in reactor power of approximately 0.27% because
of an unplanned increase in boron concentration. The direct cause was incorrectly recorded mixed bed
outlet boron concentration and failure to validate results prior to placing demineraliser in service for
lithium removal. Contributing causes were inadequate verification of information, inadequate pre-job
briefs, and inadequate communication.
WER ATL 13-0719
During operation at near full power, an operator commenced an eight-gallon reactor coolant system (RCS)
dilution, but misread the dilution counter setting and inadvertently added 78 gallons. The over-dilution
resulted in a positive reactivity change and required a subsequent boration and turbine load adjustment to
control thermal power and average coolant temperature. The direct cause was a personnel performance
error led to the reactor operator diluting 78 gallons instead of the directed eight gallons.
WER ATL 14-0081
During a startup following an outage, the estimate for achieving criticality was incorrect and the reactor did
not attain criticality as expected. The startup was delayed to reinsert rods and dilute to a lower boron
concentration before attempting startup again. The apparent cause was an increase in the hot zero power
critical boron concentration reactivity bias. An increase in the bias over the past few cycles, which was not
expected or accounted for, increased the difference between predicted and measured values and led to an
increasing difference. The contributing cause of this condition is not updating the hot zero power critical
boron concentration reactivity bias to address a changing trend.
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Attachment 2
SOER 2007-1 Rev 1 Recommendations
Standards and Expectations
1. Provide clear technical direction and standards and management expectations for reactivity control,
including the use of error reduction tools. Guidance should incorporate the following elements to
monitor and control core reactivity effectively during all modes of plant operation:
a. All core reactivity changes and mode changes must be directed by detailed operating procedures
or approved reactivity plans to prevent errors and misunderstandings. Management specifies
when procedures need to be ‘in hand’ for reactivity manipulations.
b. All core reactivity changes are made in a deliberate, carefully controlled manner. Plant
procedures shall specify which backup and redundant nuclear instrumentation as well as other
reactor and plant indications (pressures, flows and temperatures) operators shall monitor when
making reactivity changes. Reactivity changes are normally made by only one method at a time.
c. Reactor operation at low-power levels for extended periods of time is discouraged. Station
management shall carefully consider the risk of operating during off-normal plant conditions such
as low-power operation or single-loop operation (BWR). Develop appropriate contingencies and
provide training to operators before the evolution. Procedure guidance should identify potential
problems that could be encountered such as the possibility that the core may become subcritical
and predefined conditions under which operators should shut down or manually scram the
reactor.
d. The addition of positive reactivity, especially by withdrawing control rods, in response to primary
plant anomalies caused by unplanned secondary plant transients should be discouraged.
e. Policies and procedures shall specify which error-reduction tools are expected to be used in
conjunction with procedures when controlling core reactivity.
Crew Supervision
2. Shift supervision effectively direct core reactivity changes and ensure conservative decisions are made
during plant operations and fuel handling. Management should look for the following:
a. Supervisors provide oversight for core reactivity changes such as control rod motion, core flow
changes, significant steam flow changes, chemical additions or dilutions. Operators with little or
no reactor startup experience are specifically monitored by supervision during reactivity
manipulations.
b. Supervisors refrain from conducting concurrent tasks during reactivity manipulations. During
periods of reactivity manipulations or significant plant evolutions, on-shift operations supervisors
are not assigned non-operational tasks that distract them from providing proper oversight, unless
properly relieved from control room duties during periods of reactivity manipulations or
significant plant evolutions.
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c. Supervisors ensure that operators and workers conducting reactivity manipulations or working on
reactivity control equipment have been properly trained. Supervisors ensure that personnel
understand their roles and responsibilities and are briefed on management’s expectations.
d. The control room environment is managed to minimise distractions such as complex, overlapping,
or simultaneous evolutions and non-operational tasks that may divert control room operators and
supervisors from monitoring and controlling core reactivity.
e. Reactivity changes during shift turnover or shift crew briefings are to be avoided.
Reactor Engineering
3. Establish clear roles, responsibilities and procedure guidance for the interface between reactor
engineers and the operations organisation with respect to reactivity management. The following
elements should be addressed:
a. Plans for significant reactivity changes are reviewed and approved by appropriate station and
shift operations management as well as reactor engineering personnel. If plant conditions delay
planned power changes, the reactivity plan is revised to meet the new plant conditions and
approved by management.
b. Reactor engineers are available to assist operators during reactivity changes, especially during
infrequent evolutions, such as startups, shutdowns and control rod pattern adjustments.
c. Before reactor startups, core criticality predictions are determined and independently verified to
be accurate. Inconsistencies and discrepancies identified during these reviews are thoroughly
evaluated and resolved before the reactor is taken critical.
d. Core operating cycle information (for example, reactivity coefficients, burn-up characteristics over
core life and the impact of recent design changes) is provided to operators before plant startup.
Relevant information is also incorporated into appropriate procedures, training materials,
including simulator modelling if possible.
Training
4. Provide operator initial and continuing training on reactor physics fundamentals, core characteristics
over core life and how reactivity control systems operate for effective control of core reactivity during
normal, abnormal and emergency operating conditions. The following elements should be
incorporated:
a. Include fundamental reactor theory on core poisons (for example, boron, xenon, samarium and
gadolinium), how they are produced or consumed in the reactor and how reactor power changes
and core age affect core poison concentrations.
b. Identify how core reactivity coefficients vary with core life and the actions operators can
implement to properly control the reactor. Special attention should be given to coefficients that
add positive reactivity.
c. In training programmes, include applicable industry and station operating experience to reinforce
reactivity control standards and management expectations to emphasise the importance of
controlling core reactivity.
d. Training instructors reinforce management expectations during simulator training and in other
training settings to conservatively place the plant in a safe known condition if unexpected or
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uncertain plant conditions exist. Management personnel observe training sessions at least
annually to reinforce reactivity management expectations as appropriate.
e. Management expectations on the use of human performance error-reduction tools for changes to
core reactivity shall be incorporated into training objectives.
f. Where practical, provide just-in-time training to prepare shift operating crews for infrequent
evolutions such as reactor and plant startups, shutdowns and other significant changes to core
reactivity. Prior to taking a reactor critical, operators that have never taken the reactor critical
should have observed a reactor startup on the unit they are operating. During training, identify
and practice using appropriate reactor and plant indications to monitor core reactivity.
g. Reactor engineers participate in simulator training with shift operating crews at least once per
refuelling cycle or at least once every two years.
Equipment and Work Coordination
5. Verify that reactivity control equipment deficiencies are identified and promptly resolved, especially
those that reduce operator ability to monitor and control core reactivity. The following elements
should be incorporated:
a. Equipment deficiencies that potentially impact reactivity monitoring and control are highlighted
for increased emphasis during work planning and execution activities as defined by WANO GL
2005-03, Guidelines for Effective Reactivity Management. Station work management processes
ensure that other work does not interfere with the functionality of reactivity control equipment
and that proper mitigating method are documented and implemented.
b. The work management process establishes the appropriate priority and coordination of work on
systems that affect reactivity control and monitoring. Risk analysis and precautions are
documented and added to maintenance and testing procedures for reactivity control equipment.
c. When maintenance is performed on reactivity control equipment, configuration control is

maintained to ensure the system or component will be returned to its proper state.
d. Eliminate operator workarounds related to reactivity control equipment as soon as practical.

Guidance is provided to operators on specific mitigating actions for each workaround.
Appropriate controls are implemented for plant power manoeuvres that could cause undetected
reactivity changes while any reactivity control monitoring equipment is out of service for
maintenance. Refer to WANO GL 2001-02, Guidelines for the Conduct of Operations at Nuclear
Power Plants, for specific details.
Self-Assessment
6. Six months after the issuance of this SOER, and periodically thereafter, conduct a self-assessment to
determine the effectiveness of reactivity management policies, procedures and processes using WANO
GL 2005-03, Guidelines for Effective Reactivity Management. Identify and correct any performance
weaknesses. Incorporate those weaknesses that cannot be promptly corrected into the corrective
action programme for appropriate action.
WWW.WANO.ORG 17

Attachment 3
List of Reactivity Management Related Events Reported to WANO
Significant Events
WER ATL 13-0542 Unplanned Turbine Load increase while Transferring from Full Arc Mode to
Partial Arc Mode on New Digital Turbine Control System
WER ATL 14-0841 Recriticality during Soft Shutdown
Noteworthy Events
WER ATL 14-0769 Reactor Recirculation Pump Undemanded Speed Increase
WER ATL 14-1001 Condensate System Min-Flow Valve Controller Failure Leads to Reactivity
Management Event
WER ATL 14-0873 Manual Reactor Trip During Reactor Startup
WER MOW 13-0089 Improper Relative Position of the Tenth and the Ninth Groups of Clusters
WER MOW 14-0143 Emergency Protection Activation on Power Increase Rate in the Initial Range by
Low Period
WER PAR 14-0208 Shutdown Rod Bank Positioned at 218 Steps instead of in the Right Position of
228 Steps
WER PAR 14-0707 Over-insertion of the Power Compensation Bank
WER PAR 14-0743 Inappropriate Operation of the Control Rods further to Turbine Trip Resulting in
the Reactor going Subcritical
Trending Events
WER ATL 13-0001 Reactor Manually Scrammed after two Control Rods Unexpectedly Drop during
Surveillance Testing
WER ATL 13-0162 A Steam Drain Motor Operated Valve Seat Leakage Caused a Reactor Power
Increase when the Valve was Un-isolated
WER ATL 13-0166 Heater Drain Valve Modulating Open with no Demand
WER ATL 13-0192 Loop 2 Steam Generator Power Operated Relief Valve (PORV) Opened
WER ATL 13-0219 Unexpected Reactivity Change
WER ATL 13-0244 Blackout Sequencer Fault Resulting in System Actuations
WWW.WANO.ORG 18
WER ATL 13-0326 Steam Generator Feed Pump Single Cycle Speed Oscillation Causes Lowering
Steam Generator Water Levels and Operator Action to Avoid Exceeding Thermal
Power Limits
WER ATL 13-0339 Automatic Start of a Condensate Pump due to Maintenance Activities Resulting
in a Reactivity Management Event Severity Level 4
WER ATL 13-0344 Feedwater Heater Normal Level Control Valve AOV Positioner Failure Resulting in
Plant Down Power and Level 3 Reactivity Management Event
WER ATL 13-0346 AOP Entered on 5-8% Power Spike on APRMs
WER ATL 13-0369 Reactor Coolant System (RCS) Boration after placing Delithiating Demineraliser
into Service in Preparations for Plant Shutdown
WER ATL 13-0387 Heater Drain Tank Pump Trip Leads to Unexpected Power Change
WER ATL 13-0429 Rod Control Bank Automatically Withdrew Inappropriately
WER ATL 13-0433 Unit 2 Steam Generator Level Oscillations Results in Level 3 Reactivity
Management Event
WER ATL 13-0442 Manual Turbine Runback due to Low Pressure Feedwater Heater Bypass Valve
Opening during Flow Restoration
WER ATL 13-0534 Steam Dump Controller did not Respond to Operator Action in Manual Control
due to Infant Mortality of a 7300 System NCD (Circuit Driver) Card
WER ATL 13-0559 Recirculation Pump Runback and Power Reduction
WER ATL 13-0579 Control Rods Failed to Move in Response to Demand Signal
WER ATL 13-0676 Chemical and Volume Control System Mixed Bed Demineraliser Placed in Service
Without Being Properly Boron Saturated Resulting in Reactivity Management
Event
WER ATL 13-0692 Control Rod Unexpectedly Scrammed During Surveillance Testing
WER ATL 13-0702 Aborted Reactor Startup due to Source Range Monitor Period Exceeding
Procedural Limit
WER ATL 13-0713 Unexpected Change in Flux and Core Reactivity During Axial Power Shaping Rod
Group Manipulations Resulted in the Rod Being Declared Inoperable
WER ATL 13-0719 Control Room Dilutes Reactor Coolant System 78 Gallons Instead of 8 Gallons
WER ATL 13-0742 Trip of B Circulating Water Pump and Power Decrease
WER ATL 13-0744 Intermittent Condensate Feedwater System Pressure Fluctuations
WER PAR 13-0075 Incorrect Control Plug Assembly (CPA) Configuration
WER TYO 13-0111 Manual Reactor Trip to Investigate Low Poison Injection Rate from Shim Tank
WER ATL 14-0013 Control Rods Failed to Move in Response to Demand Signal
WWW.WANO.ORG 19
WER ATL 14-0081 ANO-1 Cycle 25 Deviation in Estimated Critical Boron Concentration
Two Consecutive U4 Manual Turbine Trips due to Steam Generator Water Level
WER ATL 14-0163
Lowering While Attempting to Complete Turbine Overspeed Testing
WER ATL 14-0340 Unplanned Power Reduction due to Stuck Pushbutton
Moderator Ion Exchange Resin Slurry Isolation Valve Misposition Resulted in

WER ATL 14-0389 Potential Impact on Moderator Boron Concentration and Reactivity
Management
Incorrect Valve Stroke Set Contributes to a Level Three Reactivity Management

WER ATL 14-0458
Event
WER ATL 14-0475 Axial Shape Index Control During Power Stabilisation at the End of Core Life
Post Transient Review of Manual Reactor Trip Alarm Logs Identified Potential
WER ATL 14-0496
Reactivity Management Concern
WER ATL 14-0520 Outage Extension due to Reactivity Control Valve Degradation
WER ATL 14-0540 Inadvertent Dilution During Mixed Bed Resin Changeout
WER ATL 14-0576 Unit 8 Setback Due to Low Liquid Zone Discharge Pressure
Unexpected Response of Liquid Zone Control System during the Changeover of

WER ATL 14-0601
System Compressors
WER ATL 14-0604 Reactor Trip on Linear Rate
During a Manual Blended Make Up, an 8 Gallon Boration Occurred Instead of the
WER ATL 14-0605
Planned 5 Gallon Boration
A Controlled Element Assembly Was Dropped and Recovered During the

WER ATL 14-0614
Performance of a Surveillance Test Procedure
WER ATL 14-0700 Erratic Intermediate Range Indications During Reactor Startup
Cycling Motor Operated Valves from a Failed Turbine Protection Pressure Switch
WER ATL 14-0715
Resulted in a Reactivity Addition Transient
Greater Than Anticipated Reactor Power Change When Placing Primary

WER ATL 14-0719
Demineraliser In Service Due to Valve Leak on a Parallel Primary Demineralizer
WER ATL 14-0768 Heater Drain Pump Restoration Results in Reactivity Management Level 3 Event
WER ATL 14-0771 Reactor Pressure Vessel Level Transient Due to Procedure Deficiency
Plant Transient During Control Valve Testing Using Newly Installed Digital
WER ATL 14-0797
Turbine Control System
During Unit Startup a Main Steam Atmospheric Relief Valve Opened

WER ATL 14-0810
Unexpectedly Causing a Reactivity Challenge
WER ATL 14-0838 Unplanned Boron Addition to Moderator Resulted in a Drop of the Average Zone
WWW.WANO.ORG 20
Level and the Unit Transient
WER ATL 14-0842 Unit 2 Transient due to Human Performance Error
Reactor Water Level Controller’s Level Set Point Increased without Operator
WER ATL 14-0846
Action
WER ATL 14-0874 Unplanned reduction In Reactor Coolant System Pressure and Temperature
Technical Specification Required Shutdown due to Dropped Control Element

WER ATL 14-0930
Assembly
WER ATL 14-0935 Loss of Control Rod Position Indication During Startup from Refuelling Outage
WER ATL 14-0977 Unplanned Manual Reactor Trip Due to Shutdown Margin Determination
Unit 2 Main Steam Polarity Unit Tripped leading to a Reactor Power Excursion
WER ATL 14-0997
and Entry into Incident Procedure due to Reasons Unknown
WER ATL 14-1000 Unexpected Loss of Heater Drains while Lowering Reactor Power
Irrational Indication Received on Liquid Zone Control System Results in Reactivity

WER ATL 14-1074
Management Near-Miss Event
WER ATL 14-1097 Fuel Conditioning Limit Approached Due to Recirculation Pump Speed Instability
WER PAR 14-0111 Automatic Reactor Scram due to the Drop of a Control Rod
WER PAR 14-0139 Grey Control Rods Below Calibration Curve during Load Increase
‘High Flux When Shutdown’ Alarm Disabled during Rod-Drop Test, Resulting in
WER PAR 14-0155
Technical Specification Violation
Manual Shutdown Due to Loss of Data Processing System & Reduction in

WER PAR 14-0173
Superheat
WER PAR 14-0186 Document Deviation Resulting in Breach of Hot Shutdown Boron Concentration
WER PAR 14-0402 Over-insertion of the Shim Control Rod Banks
WER PAR 14-0525 Unplanned withdrawal of Control Rod during the Required Surveillance test
WER PAR 14-0540 Uncontrolled Power increased after Loss of Main Circulation Pump
Inappropriate Reactor Control Manipulations Resulting in Pressure/Temperature

WER PAR 14-0574
Excursion and a Technical Specification Violation
WER PAR 14-0648 Exceeded Power Peaking Factor Limitation during Startup after Refuelling
A decrease in the level of the Spent Fuel Pool and a decrease in Nominal Thermal
WER PAR 14-0715
Power during the Commissioning of the Boron Thermal Regeneration System
Over-insertion of Power Compensation Bank following the Omission to Return

WER PAR 14-0738
Rod Control to AUTO
WER PAR 14-0807 Reactor 3 Extra High T1 Temperature Trip Unit Channel 1 Calibration – Plant
WWW.WANO.ORG 21
Transient
Modification of the Control Rod configuration in the core after identifying the
WER PAR 14-0815
risk of exceeding the remaining life of a Rod if it were to remain inserted.
Automatic Reactor Scram due to Failure of a Level Controller of Liquid Zone

WER TYO 14-0071
Control (LZC) of Zone #5
WER TYO 14-0123 Incorrect Valve Position Resulted in Minor Dilution of Reactor Coolant System
WER TYO 14-0152 A Heater Drain Tank dump valve positioned failure
WER ATL 15-0026 Software Issue with Core Monitoring Software System
WER ATL 15-0033 Brief Reactor Power Increase to 100.66%
Steam Flow Proportional Amplifier Degraded Causing Main Steam Line Flow to
WER ATL 15-0128
Decrease
"A" Reactor Feed Pump Inverter Malfunction Caused Recirculation Pump

WER ATL 15-0150
Runback
Average Zone Level Continued to Rise While Reducing Moderator Conductivity

WER ATL 15-0151
During the Unit Startup Resulting in a Partial Drop of Two Control Absorbers
An Operating Technical Specification Non-Compliance Event occurred when the

WER ATL 15-0160 Axial Flux Deviation was not Restored to ±5% of the Reactor Protection Target
Band within 15 minutes, with Unit Power >87% Power
WER ATL 15-0183 Unit 7 Moderator Cover Gas Transient - Shutdown System 1 Manual Trip
WER ATL 15-0192 Unplanned Power Reduction Due to Recirculation Pump Trip
WER ATL 15-0199 Feedwater Heater Isolation Results in Unplanned Downpower
Deficiencies in Engineering Change Installation on Liquid Zone Control System

WER ATL 15-0203
Resulted in Loss of Control of Several Zones and Potential Operability Concern
WER ATL 15-0228 Human Error while Performing Estimate Critical Condition Calculations
Plant’s Electrical Load Reduced due to Inadvertent Control Rod Drive Mechanism
WER MOW 15-0030
(CRDM) 56-21 Insertion into the Core
Misalignment of control rod assembly K4 compared to bank G2 covered by group

WER PAR 15-0083
1 LCO RGL3
Automatic reactor scram with rapid variation in nuclear flux (dΦ/dt signal) due
WER PAR 15-0090
to the closing of breaker module 3RGL002UP
WER TYO 15-0016 Rx Trip during the action against the sign of SG Tube Leakage
Other Events
WER ATL 13-0512 Unexpected 1/2 step insertion of Control Bank D rods
WWW.WANO.ORG 22
WER ATL 13-0750 Liquid Zone Levels Delay Power Increase
WER ATL 13-0774 Reactor Setback During Fuelling
Feedwater Regulating Valve Fails Open Causing a Momentary Change in Core

WER ATL 13-0815
Thermal Power
Level 4 Reactivity Management Event Due to Bleed Steam Coil Drain Tank
WER ATL 13-0850
Manway Leak
3C Feedwater Regulating Valve Oscillations during Auxiliary Feedwater

WER ATL 14-0112
Operation
WER ATL 14-0260 Recirculation Pump A Run Back Results in Power Reduction
Control Rod Drive Exercising When Not Required Results in Reactivity

WER ATL 14-0270
Management Level 3 Event
Two Unplanned Power Increases of 6 MWt and 11 MWt due to the Main Steam
WER ATL 14-0271
to Deaerator Control Valve Opening 5%
Linear Voltage Differential Transformer Position Indication Change Adjusted

WER ATL 14-0272
Turbine Control Valve Position Causing a Step Change in Megawatts
WER ATL 14-0275 Middle Heater Drain Pump Tripped While Preparing to Shift Pumps
Sluggish Reactor Recirculation Pump Response Results in Unplanned Step

WER ATL 14-0316
Changes
WER ATL 14-0462 Core Loading Methodology Calculations
Greater Than Anticipated Control Rod Movement When Placing Primary

WER ATL 14-0529
Demineraliser In Service Due To Temperature Difference
Moisture Separator Reheater Temperature Control Valve failed closed Resulting

WER ATL 14-0542
in a Level 4 Reactivity Event
Delay in returning Control Rods from Manual to Auto Control following a Fuel
WER PAR 14-0461
Channel Standpipe Leak Check
Emission of a Spurious Reactor Scram Signal due to High Flux Measured on

WER PAR 14-0514
Intermediate Range Channel
Secondary Plant Transient in Feedwater Heater System Led to a Reactivity

WER ATL 15-0114
Management Event
WWW.WANO.ORG 23
ATLANTA
LONDON & HONG KONG
MOSCOW
PARIS
TOKYO
WORLD ASSOCIATION OF NUCLEAR OPERATORS
www.wano.org & www.wano.info

Analysis of Reactivity Management Events

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Analysis of Reactivity Management Events

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REPORT

RPT ǀ 2015-6 July 2015

THIS WANO REPORT APPLIES TO ALL REACTOR TYPES

Liability disclaimer notice

Report ǀ RPT 2015-6

Author Date Reviewer Approval

Arshad Mahmood 24 July 2015 Michael Ballard Jo Byttebier

Reason for Changes:

REPORT ǀ RPT 2015-6

REPORT ǀ RPT 2015-6

Summary of consequential reactivity management events

Reactivity Management Events Related to Gaps in Human Performance

Reactivity Management Events Related to Gaps in Equipment Performance

Summary of actions taken by plants in response to events reported to WANO

1. Self-assessing and improving implementation of the recommendations in SOER 2007-1 Rev 1,

7. Including reactivity management OE events in simulator training.

Specific observations from WANO PR AFIs

Human Performance Related AFIs

Equipment Performance Problems Contributing to Reactivity Management AFIs

Management Weaknesses Related AFIs

SOER 2007-1 Recommendation Implementation Status

1. SOER 2007-1 Rev 1, Reactivity Management

2. GL 2005-03 Rev 1, Guidelines for Effective Reactivity Management

3. AP 913 Rev 4, Equipment Reliability Process

4. SOER 2013-1, Operator Fundamental Weaknesses

5. GL 2002-02, Excellence in Human Performance

REPORT ǀ RPT 2015-6

Analysis of the OE Events

Figure 1 : Reactivity Management Events reported to

Figure 2: Number of Reactivity Management Events

Figure 3 : Reactor Status at the time of Event

Figure 4 : Causes of Reactivity Management Events

Systems involved in Reactivity Management Events

Figure 5 : Systems involved in Reactivity Management Events

16% liquid zone control

• Ageing electronic components

WER PAR 14-0173

WER ATL 13-0692

WER ATL 14-0614

WER ATL 14-0977

WER ATL 13-0676

WER ATL 13-0719

WER ATL 14-0081

REPORT ǀ RPT 2015-6

SOER 2007-1 Rev 1 Recommendations

Standards and Expectations

Equipment and Work Coordination

c. When maintenance is performed on reactivity control equipment, configuration control is

d. Eliminate operator workarounds related to reactivity control equipment as soon as practical.

REPORT ǀ RPT 2015-6

List of Reactivity Management Related Events Reported to WANO

WER ATL 14-0841 Recriticality during Soft Shutdown

WER ATL 14-0769 Reactor Recirculation Pump Undemanded Speed Increase

WER ATL 14-0873 Manual Reactor Trip During Reactor Startup

WER PAR 14-0707 Over-insertion of the Power Compensation Bank

WER ATL 13-0219 Unexpected Reactivity Change

WER ATL 13-0244 Blackout Sequencer Fault Resulting in System Actuations

WER ATL 13-0346 AOP Entered on 5-8% Power Spike on APRMs

WER ATL 13-0429 Rod Control Bank Automatically Withdrew Inappropriately

WER ATL 13-0559 Recirculation Pump Runback and Power Reduction

WER ATL 13-0744 Intermittent Condensate Feedwater System Pressure Fluctuations

WER PAR 13-0075 Incorrect Control Plug Assembly (CPA) Configuration

WER ATL 14-0340 Unplanned Power Reduction due to Stuck Pushbutton

Moderator Ion Exchange Resin Slurry Isolation Valve Misposition Resulted in