tsutsuji
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Cabinet investigation committee interim report translation (part 3)
part 1 : https://www.physicsforums.com/showpost.php?p=3687263&postcount=11983
part 2 : https://www.physicsforums.com/showpost.php?p=3688404&postcount=12005
What follows is mostly a restatement of already mentioned events with some comments and, I am afraid, quite few new details :
http://icanps.go.jp/111226Honbun4Shou.pdf translation of pages 111 (35/170) - 114 (38/170)
e Indication of problem items (concerning the judgement of the IC's operation status and the response to it)
(a) judgement by the shift operators on duty
1) At the point of time after around 15:37 on March 11 when all of unit 1's AC electric power and DC electric power were lost, nobody among the shift operators on duty had an awareness of the problem posed by the possibility that the IC's isolation valves might be closed due to the fail-safe function.
At that time, the shift operators on duty were in an ongoing situation where one cannot determine clearly whether the IC is operating or not, but after around 16:42 on the same day, the reactor water level gauge became available and it was confirmed that the reactor water level was decreasing. Furthermore, after the reactor water level gauge went down scale and became unclear again, the shift operators on duty decided to go inside unit 1's reactor building to check the amount of water in the IC's condenser tank, but they renounced because the radiation dose was high.
Although this sequence of events had taken place, at that time, the shift operators on duty did not come up with the idea to verify the IC's operation status by checking whether steam is released from the IC's exhaust vent on the western wall of unit 1's reactor building. It can be thought that one of the main reasons for this is that the shifts operators on duty had no previous experience of operating unit 1's IC, and had received no training or education enabling them to take countermeasures based on a suitable judgement in real operation conditions.
2) Although the shift operators on duty were not able to think about a suitable method to check the IC's operation status, because the reactor water level was in a decreasing trend, at around 17:30 the possibility that the IC was not operating sufficiently had already entered their mental horizon, and in order to secure alternative water injection means, they started the D/DFP and put it in standby mode.
Furthermore, despite the fact that after the tsunami arrival they had left the three other isolation valves in an open status and were controlling the IC's operation by opening and closing the sole return line isolation valve (MO-3A), at around 18:18 on the same day, as it was confirmed that the green lamps indicating the full closure of not only the return line isolation valve (MO-3A) but also of the feed line isolation valve (MO-2A), were lit (note 34), the shift operators on duty came up with the idea that there was a possibility that the fail-safe function had been operated, and thought that there was a high probability that the other isolation valves on the inner side of the primary containment vessel (MO-1A, 4A) had also been fully closed by the fail-safe function.
Note 34: At that time, the lamps on the control panel indicating the status of the isolation valves on the inner side of the primary containment vessel were extinguished and it was impossible to check their open or closed status.
Also, at that time, at long last, the shift operators on duty came up with the idea to check the IC's operation status by observing the status of the steam released from the IC's exhaust vent, but they only looked beyond unit 1's reactor building, and although one cannot be sure that this was the steam released from the IC's exhaust vent, they did not attempt a direct visual observation.
Anyway, at that time, judging that the quantity of steam released by the IC's exhaust vent is small and thinking that the quantity of water remaining in the IC's condenser tank might have become small, in order to prevent pipe damage, at around 18:25 on the same day, the shift operators on duty decided to fully close the return line isolation valve (MO-3A).
Then, as the IC was not functioning, and as other water injection means could not be used due to the loss of electric power, thinking that there is no other solution than injecting water through the FP line with the D/DFP, at around 18:30 on the same day, in order to enable water injection into the reactor through the FP line, the shift operators on duty started to manually operate the valves.
It can be said that such judgement by the shift operators on duty, though late as it was, was rational as regards its content.
Also, as it can be thought that at around 18:25 on the same day the IC was already almost not functioning, it can be thought that the impact on the reactor status of the decision by the shift operators on duty to shutdown the IC, was low.
3) However, as a result of the difference between the D/DFP output pressure and the reactor pressure, it is physically impossible to perform water injection into the reactor with the D/DFP without depressurizing the reactor by opening the SR valve, and the shift operators on duty were well aware of this.
Then, as it was impossible, as a consequence of the loss of electric power, to remotely open the SR valve from the units 1 and 2 central control room, the shift operators on duty should have clearly indicated the problem concerning the IC's operating status to the power plant response headquarters, and they should have requested their help so that the batteries that are necessary to open the SR valve, as part of the construction of an alternative water injection means, are delivered and connected to the contacts on the rear side of the control panels.
However, at that time, the power plant response headquarters was mistakenly believing that the IC was operating normally, and was not aware that the above mentioned help was needed. Also, no traces whatsoever were found that, from the evening to the night on the same day, batteries had been gathered on the power plant premises for a total amount of 120 V as needed for a depressurizing operation performed with the SR valve.
Hence, it can be thought that, at least, the shift operators on duty did not sufficiently report to the power plant response headquarters the IC's operation status or the necessity to urgently deliver and connect the batteries that are needed to perform the SR valve opening operation.
(b) Reporting of the opening operation of return line isolation valve (MO-3A)
1) It is clear from the hand-written mentions on the memos of the electric power group who was receiving the reports at the power plant response headquarters, that the shift operators on duty reported to the power plant response headquarters the opening operations of the feed line isolation valve (MO-2A) and of the return line isolation valve (MO-3A) at around 18:18 on March 11 and of the return line isolation valve (MO-3A) at around 21:30 on the same day.
However, the closure operation of the return line isolation valve (MO-3A) by the shift operators on duty at around 18:25 on the same day is not mentioned in the hand-written memos of the electric power group of the power plant response headquarters or in any other record. Furthermore, among the members of the electric power group of the power plant response headquarters who were receiving unit 1's reports or among the persons who wrote the above mentioned hand-written memos or among other members of the power plant response headquarters or of the main office response headquarters, nobody testified anything purporting that "I was aware at that time that the return line isolation valve (MO-3A) had been closed". Actually, plant manager Yoshida to begin with, as well as the other members of the power plant response headquarters and of the main office response headquarters, testified purporting that "at that time I thought the IC was under operation".
2) The head of the shift operators on duty at that time testified purporting that "I phoned to the electric power group of the power plant response headquarters by fixed phone, and reported the problem concerning the IC's operation status saying something like "As, when we started the IC, the quantity of generated steam was small, there is a possibility that the quantity of water in the IC's condenser tank is not sufficient, and I wonder if we should not suspect that the IC is not functioning "". However, the head of the shift operators does not remember clearly reporting that the IC had been shutdown by closing the return line isolation valve (MO-3A).
About this, the person at the electric power group of the power plant response headquarters who was receiving the reports about unit 1 testified purporting that "I received a report from the head of the shift operators on duty saying something like "We started the IC, and as the quantity of generated steam is small, there is a possibility that the quantity of water in the condenser tank is small", and at that time, I thought that it was possible to operate the IC. Also, if the quantity of water in the condenser tank is not sufficient, it would be enough to refill the cooling water by using the FP line, and I thought that the shift operators on duty could respond to this sort of problem all by themselves". Actually, according to the head of the shift operators on duty, when the report receiving person received the report about the construction of a line injecting water into the reactor through the FP line and using the D/DFP, his reply suggested that he mistakenly believed that it was a line aimed at refilling the [IC's] condenser tank with cooling water, and no matter how many times the head of the shift operators on duty tried to correct him, it seemed that he did not sufficiently understand.
Under such circumstances, in view of the importance of information, the head of the shift operators on duty should have sufficiently explained so that the misunderstanding of the power plant response headquarters' electric power group's person in charge clears up. It can be thought that the misunderstanding would have been easily cleared up if it had been clearly explained that "As the isolation valve was closed, the IC is shutdown, and it is necessary to inject water into the reactor by using the D/DFP, and we would like the power plant response headquarters to help because we don't have the batteries that must be used to open the SR valve as needed for the depressurization operation". However, the member of the power plant response headquarters' electric power group who was receiving the reports about unit 1 testified that he did not receive the needed clear explanation, and, as a matter of fact, no trace was found at the power plant response headquarters of any concrete preparation for unit 1's alternative water injection at that time.
3) Anyway, the shift operators on duty did not accurately communicate to the power plant response headquarters and to the main office response headquarters the information about the IC's operation status, which was at that time one of the most important informations concerning unit 1, and it is clear that a large awareness gap was generated between the power plant response headquarters and the shift operators on duty, and it is acknowledged that no sufficient mutual understanding took place between the shift operators on duty and the power plant response headquarters.
(c) Judgement by the power plant response headquarters and by the main office response headquarters
(to be continued)
part 1 : https://www.physicsforums.com/showpost.php?p=3687263&postcount=11983
part 2 : https://www.physicsforums.com/showpost.php?p=3688404&postcount=12005
What follows is mostly a restatement of already mentioned events with some comments and, I am afraid, quite few new details :
http://icanps.go.jp/111226Honbun4Shou.pdf translation of pages 111 (35/170) - 114 (38/170)
e Indication of problem items (concerning the judgement of the IC's operation status and the response to it)
(a) judgement by the shift operators on duty
1) At the point of time after around 15:37 on March 11 when all of unit 1's AC electric power and DC electric power were lost, nobody among the shift operators on duty had an awareness of the problem posed by the possibility that the IC's isolation valves might be closed due to the fail-safe function.
At that time, the shift operators on duty were in an ongoing situation where one cannot determine clearly whether the IC is operating or not, but after around 16:42 on the same day, the reactor water level gauge became available and it was confirmed that the reactor water level was decreasing. Furthermore, after the reactor water level gauge went down scale and became unclear again, the shift operators on duty decided to go inside unit 1's reactor building to check the amount of water in the IC's condenser tank, but they renounced because the radiation dose was high.
Although this sequence of events had taken place, at that time, the shift operators on duty did not come up with the idea to verify the IC's operation status by checking whether steam is released from the IC's exhaust vent on the western wall of unit 1's reactor building. It can be thought that one of the main reasons for this is that the shifts operators on duty had no previous experience of operating unit 1's IC, and had received no training or education enabling them to take countermeasures based on a suitable judgement in real operation conditions.
2) Although the shift operators on duty were not able to think about a suitable method to check the IC's operation status, because the reactor water level was in a decreasing trend, at around 17:30 the possibility that the IC was not operating sufficiently had already entered their mental horizon, and in order to secure alternative water injection means, they started the D/DFP and put it in standby mode.
Furthermore, despite the fact that after the tsunami arrival they had left the three other isolation valves in an open status and were controlling the IC's operation by opening and closing the sole return line isolation valve (MO-3A), at around 18:18 on the same day, as it was confirmed that the green lamps indicating the full closure of not only the return line isolation valve (MO-3A) but also of the feed line isolation valve (MO-2A), were lit (note 34), the shift operators on duty came up with the idea that there was a possibility that the fail-safe function had been operated, and thought that there was a high probability that the other isolation valves on the inner side of the primary containment vessel (MO-1A, 4A) had also been fully closed by the fail-safe function.
Note 34: At that time, the lamps on the control panel indicating the status of the isolation valves on the inner side of the primary containment vessel were extinguished and it was impossible to check their open or closed status.
Also, at that time, at long last, the shift operators on duty came up with the idea to check the IC's operation status by observing the status of the steam released from the IC's exhaust vent, but they only looked beyond unit 1's reactor building, and although one cannot be sure that this was the steam released from the IC's exhaust vent, they did not attempt a direct visual observation.
Anyway, at that time, judging that the quantity of steam released by the IC's exhaust vent is small and thinking that the quantity of water remaining in the IC's condenser tank might have become small, in order to prevent pipe damage, at around 18:25 on the same day, the shift operators on duty decided to fully close the return line isolation valve (MO-3A).
Then, as the IC was not functioning, and as other water injection means could not be used due to the loss of electric power, thinking that there is no other solution than injecting water through the FP line with the D/DFP, at around 18:30 on the same day, in order to enable water injection into the reactor through the FP line, the shift operators on duty started to manually operate the valves.
It can be said that such judgement by the shift operators on duty, though late as it was, was rational as regards its content.
Also, as it can be thought that at around 18:25 on the same day the IC was already almost not functioning, it can be thought that the impact on the reactor status of the decision by the shift operators on duty to shutdown the IC, was low.
3) However, as a result of the difference between the D/DFP output pressure and the reactor pressure, it is physically impossible to perform water injection into the reactor with the D/DFP without depressurizing the reactor by opening the SR valve, and the shift operators on duty were well aware of this.
Then, as it was impossible, as a consequence of the loss of electric power, to remotely open the SR valve from the units 1 and 2 central control room, the shift operators on duty should have clearly indicated the problem concerning the IC's operating status to the power plant response headquarters, and they should have requested their help so that the batteries that are necessary to open the SR valve, as part of the construction of an alternative water injection means, are delivered and connected to the contacts on the rear side of the control panels.
However, at that time, the power plant response headquarters was mistakenly believing that the IC was operating normally, and was not aware that the above mentioned help was needed. Also, no traces whatsoever were found that, from the evening to the night on the same day, batteries had been gathered on the power plant premises for a total amount of 120 V as needed for a depressurizing operation performed with the SR valve.
Hence, it can be thought that, at least, the shift operators on duty did not sufficiently report to the power plant response headquarters the IC's operation status or the necessity to urgently deliver and connect the batteries that are needed to perform the SR valve opening operation.
(b) Reporting of the opening operation of return line isolation valve (MO-3A)
1) It is clear from the hand-written mentions on the memos of the electric power group who was receiving the reports at the power plant response headquarters, that the shift operators on duty reported to the power plant response headquarters the opening operations of the feed line isolation valve (MO-2A) and of the return line isolation valve (MO-3A) at around 18:18 on March 11 and of the return line isolation valve (MO-3A) at around 21:30 on the same day.
However, the closure operation of the return line isolation valve (MO-3A) by the shift operators on duty at around 18:25 on the same day is not mentioned in the hand-written memos of the electric power group of the power plant response headquarters or in any other record. Furthermore, among the members of the electric power group of the power plant response headquarters who were receiving unit 1's reports or among the persons who wrote the above mentioned hand-written memos or among other members of the power plant response headquarters or of the main office response headquarters, nobody testified anything purporting that "I was aware at that time that the return line isolation valve (MO-3A) had been closed". Actually, plant manager Yoshida to begin with, as well as the other members of the power plant response headquarters and of the main office response headquarters, testified purporting that "at that time I thought the IC was under operation".
2) The head of the shift operators on duty at that time testified purporting that "I phoned to the electric power group of the power plant response headquarters by fixed phone, and reported the problem concerning the IC's operation status saying something like "As, when we started the IC, the quantity of generated steam was small, there is a possibility that the quantity of water in the IC's condenser tank is not sufficient, and I wonder if we should not suspect that the IC is not functioning "". However, the head of the shift operators does not remember clearly reporting that the IC had been shutdown by closing the return line isolation valve (MO-3A).
About this, the person at the electric power group of the power plant response headquarters who was receiving the reports about unit 1 testified purporting that "I received a report from the head of the shift operators on duty saying something like "We started the IC, and as the quantity of generated steam is small, there is a possibility that the quantity of water in the condenser tank is small", and at that time, I thought that it was possible to operate the IC. Also, if the quantity of water in the condenser tank is not sufficient, it would be enough to refill the cooling water by using the FP line, and I thought that the shift operators on duty could respond to this sort of problem all by themselves". Actually, according to the head of the shift operators on duty, when the report receiving person received the report about the construction of a line injecting water into the reactor through the FP line and using the D/DFP, his reply suggested that he mistakenly believed that it was a line aimed at refilling the [IC's] condenser tank with cooling water, and no matter how many times the head of the shift operators on duty tried to correct him, it seemed that he did not sufficiently understand.
Under such circumstances, in view of the importance of information, the head of the shift operators on duty should have sufficiently explained so that the misunderstanding of the power plant response headquarters' electric power group's person in charge clears up. It can be thought that the misunderstanding would have been easily cleared up if it had been clearly explained that "As the isolation valve was closed, the IC is shutdown, and it is necessary to inject water into the reactor by using the D/DFP, and we would like the power plant response headquarters to help because we don't have the batteries that must be used to open the SR valve as needed for the depressurization operation". However, the member of the power plant response headquarters' electric power group who was receiving the reports about unit 1 testified that he did not receive the needed clear explanation, and, as a matter of fact, no trace was found at the power plant response headquarters of any concrete preparation for unit 1's alternative water injection at that time.
3) Anyway, the shift operators on duty did not accurately communicate to the power plant response headquarters and to the main office response headquarters the information about the IC's operation status, which was at that time one of the most important informations concerning unit 1, and it is clear that a large awareness gap was generated between the power plant response headquarters and the shift operators on duty, and it is acknowledged that no sufficient mutual understanding took place between the shift operators on duty and the power plant response headquarters.
(c) Judgement by the power plant response headquarters and by the main office response headquarters
(to be continued)
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