International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
Review of Narora Unit 1 Fire Event of March 1993
Srisht Pall Singh
Abstract: On 31st March 1993, a major fire broke out in NAPS unit 1 while it was generating 185 MWe power level. The fire had been
triggered by sudden rupture at the roots of the 5 th stage blades in the low pressure turbine leading to leakage of hydrogen from the
generator cooling circuit. It led to deflagration in the turbine building which propagated along the cable ducts through several barriers
to the control room and emergency control room. This fire disabled emergency power supply in about 7 minutes. Explosive sounds were
experienced, and blue flames was observed in the turbine building by an operator. The ensuing fire propagated via power and control
cables to the control room and emergency control room disabling all power supply sources, from class I to class IV types. This beyond-
SBO situation lasted around 17 hours. It disabled all safety functions after the initial scram. Hence, the safety functions to actuate long
term sub-criticality by poison injection, and residual heat removal were actuated manually, at great personal risk. The fire was brought
under control in 90 minutes and was extinguished manually by use of portable fire pumps, in around 9 hours. This fire event ranked
third after Chernobyl and Fukushima fire events in terms of severity. However, despite manifest signs of common cause failures and
weak safety culture in the utility (NPCIL) and failure of all power sources from class I to class IV, this event was ranked at level 3 on
INES scale, namely, a simple incident. The utility (NPCIL) had undertaken measures, including strengthened systems and procedures
for fire control to address weaknesses that were dormant for over a decade in its NPPs. In this study, this event is reviewed and strengths
and weaknesses of Indian NPP program and its regulatory control as they existed at the time of the event are described. Those strengths
are weaknesses are also described. Suggestions are offered to weed out any dormant weaknesses.
Keywords: fire; explosion; beyond SBO; common cause failures; weak safety culture;
1. Description of the Fire Event this time by natural circulation (thermo-siphoning effect),
the heat being released in the atmosphere through the
On 31st March 1993, a major fire broke out in NAPS unit 1 Atmospheric Steam Discharge Valves, and the steam
while it was generating 185 MWe power level. The fire had generators being fed by the diesel-powered fire water
been triggered by sudden rupture at the roots of 5th stage pumps.
blades in the low pressure turbine and leakage of hydrogen
from the generator cooling circuit. It led to deflagration in The Narora-1 event represents loss of several safety systems
the turbine building which propagated along the cable ducts and operational systems due to an internal hazard (internal
through several barriers and disabled emergency power fire). The main systems lost were the AC and DC buses, the
supply in about 7 minutes. This was loss of all power was control room and the emergency control room. The effective
more severe than the Station Black Out situation (SBO). barriers were the successful emergency actions by the
personnel, several passive design features (including the low
The sequence of events have been graphically described in thermal power) and a third EDG placed sufficiently
reference [1] as follows: physically separated from the plant. UNQUOTE
QUOTE. Simultaneously, a strong and powerful sound The reactor was manually tripped. However, due to
resembling an explosion was heard by control room staff on complete loss of power, other safety functions had to be
duty inside and outside the turbine building. Vibrations on performed manually, in the dark, at great personal risk. For
the floor were also experienced by the control room staff. long term shut down, the Gravity Addition of Boron System
On investigation, a huge fire was observed on the operating was actuated by operators entering the stream generator
floor and below near the slip ring end of the generator. Fire room around 2 hours into the incident.
near the turbo-generator (TG) set of Unit 1 with bluish
flames was also observed by the crane operator from his Due to loss of power, the engineered emergency core
crane cabin parked on the side of Unit [Link]. cooling system could not be activated. The reactor decay
heat was being removed through action of the steam relief
Reference [2] describes the further sequence as follows: valves, which opened in about 7 minutes into the incident.
The reactor coolant circuit entered a thermo-syphon mode
QUOTE The incident was a “Beyond Design Basis and the steam generators, which were at 48 bars pressure
Accident”, as SBO including class I and II failure was not initially, removed the transferred heat even without water
considered during the design stage. Due to the ineffective make-up for about 5 hours. After 5 hours, the steam
fire barriers, fire spread rapidly and finally a large amount generators were down to atmospheric pressure on the shell
of smoke ingressed into the control room, so the staff had to side. This would indicate that core cooling via steam
leave. . It was not possible to take charge of the situation generator relief valves was getting depleted with time and
from the emergency control room, as by reason of the loss of was not far from being dry on the shell side after 5 hours. It
control power supply no indications on Narora-1 panel were also indicated that sustained steam-relief was achieved
available. Important parameters had to be directly measured manually. The injection of fire water by external fire-
from field. This resulted in the blind operation of the plant. fighting pumps saved the reactor unit from major release of
Firefighting was started by using two diesel engine driven radio-active materials from the PHT system.
fire water pumps. To establish the heat sink diesel driven
fire water pumps were started to feed the secondary side of The beyond-SBO situation lasted around 17 hours, and core
the steam generators and cooling was maintained during cooling was restored in 19 hours.
Volume 8 Issue 10, October 2019
[Link]
Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20202268 10.21275/ART20202268 1714
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
The initiator of this accident was sudden failure of two hydrogen fire. These reactor units, in chronological order,
turbine blades in the 5th stage of the low pressure turbine. are as follows:
The consequent unbalance of the generator shaft caused its Muhleberg, PWR, Switzerland, 1971 – first known large
oil lubricated seals to rupture and the hydrogen, which was turbine building fire
used as coolant for the generator leaked out, causing Browns Ferry BWR units 1 and 2, USA -large scale cable
explosions and secondary fire. fire damaged control building and panels, led to SBO
Beloyarsk PWR 1978 – Russia - large scale cable fire
This fire lit the cables insulation and spread from the turbine damaged control building and panels
room through cable joints to the Control Equipment Room, Armenia PWR, Armenia 1982 – large cable gallery fire, led
Control Room and Emergency Control Room, forcing their to SBO
evacuation. These cables lacked fire-resistant insulation and Maanshan PWR unit 1, Taiwan 1985 – turbine blade
the cable penetrations were not qualified to resist standard ejection & large scale turbine building fire
fires. Vandelos PWR, Spain 1989 - turbine blade ejection and
large scale turbine building fire
Summary of similar fire events in nuclear power stations Salem PWR units 1 and 2, USA 1991 - turbine blade failure
from 1988 to 1996 [3] and large scale turbine building fire
Reference [3] gives descriptions and evaluations of 25 fire Narora PHWR unit 1, India 1993 - turbine blade failure and
incidents in nuclear power plants from 1988 to [Link] large scale turbine building fire led to SBO
these 25 events, involving fires,8 events cover turbine oil Table 1 shows the in NPPs listed above and nature of
leakage leading to the fire, including 4 incidents wherein the consequences of these fire events.
fire was initiated by rupture of turbine blades, leading to
Table 1: List of similar fire events and their consequences in NPPs - [C]
NPPs Muhleberg Browns Beloyarsk Armenia Maanshan Unit Vandelos Salem PWR Narora unit 1
Fire effects PWR Ferry BWR PWR unit 2 PWR 1 PWR Unit 1 PWR units 1 & 2 PHWR
Severe fire No no Yes Yes Yes Yes Yes Yes
Fire propagated No yes Yes Yes No No No Yes
Smoke propagated No yes Yes Yes No Yes No Yes
Smoke in control room No yes Yes Yes No Yes No Yes
Control room vacated No No Yes No No No No Yes
Challenging fire No yes Yes Yes No Yes No Yes
Multi systems impacted No yes Yes Yes No Yes No Yes
Loss of core cooling No No Not known Yes No No No Yes
Loss of instrumentation No no Yes Yes No No No Yes
Time to control fire Not known 6:55 hrs. 17:05 hrs. 6:05 hrs. Not known 3:51 hrs. Not known 1:30 hrs.
Time to put out fire 2:07 hrs. 7:25 hrs. 21:40 hrs. 7:03 10 hrs. 6:21 hrs. 0:15 hrs. 9:00 hrs.
2. Corrective and repair actions by the utility (6) Mineral wool insulation, which used to catch fire due to
(NPCIL) [4] oil leakage, has been replaced by calcium silicate as an
insulation material on steam pipelines and below turbine.
The utility NPCIL have undertaken several measures to Similarly in hot, active and inaccessible places the
minimize the chances of occurrences of fires and of limiting insulation material has been changed to „reflective metallic
their effects should any fires occur. These include the mirror insulation‟.
following: (quoted text is shown in italics) (7) Hydrogen leak detectors have been provided near
(1) Storage of combustible materials has been limited to generator hydrogen addition station, generator bearing and
bare minimum in operating areas and where such materials near hydrogen dryer areas.
can be eliminated it has been done. This has been ensured (8) Installation and testing of fire detectors and installation
through `work permits‟ and regular field surveys. of additional fire detectors insensitive areas like cable vaults
(2) Preventive maintenance and energy conservation and cable galleries.
measures have been initiated to prevent electrical accidents. (9) Fire watch during `hot work‟ in sensitive areas and
(3) Regular measurements of bearing temperature of motors special work permits for carrying out such jobs.
are done to avoid fire due to overheating. Condition (10) Investigation and analysis of fire incidents.
monitoring of equipment is also done to minimize fire risk (11) Segregation of power and control cables and
due to overheating, friction and jamming of internal parts. application of fire retardant coating on cables,
(4) Smoking inside operating island is strictly prohibited at
all sites. The following steps for training of fire-fighting personnel
(5) A number of training and awareness programs are have been instituted:
initiated on fire safety aspects. (12) Systematic training of fire staff to familiarize them of all
critical areas of the plant.
NPCIL have also made important changes to equipment, (13) Periodic fire emergency drills and review of the results
including the following: under a standard format.
(15) All operation and maintenance staff was trained on
fire-fighting operations and on the use of Self-Contained
Breathing Apparatus.
Volume 8 Issue 10, October 2019
[Link]
Licensed Under Creative Commons Attribution CC BY
Paper ID: ART20202268 10.21275/ART20202268 1715
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2018): 7.426
(11) Fire squads have been formed at all stations to cover also involved manual actions in the reactor building, in
all three shifts and all areas of the plant to attack any fire at complete dark.
its initial stage itself before arrival of Fire Station
Personnel. The actions of the operators in activating the GRAB system
These fire squad personnel have been given detailed fire about 2 hours into the event, in controlling the fire in 90
safety training. minutes and extinguishing in 9 hours, and in lining up the
portable fire water supply in around 5 hours is indeed
Classification of the event on INES scale noteworthy. It testifies to their qualification, training and
This incident had been classified as level 3 on the INES dedication to their duties, even in circumstances of grave
scale, i.e. an event wherein echelons of defence in depth, personal risk.
engineered barriers and systems had been degraded. This
was an obvious understatement, as all echelons, barriers and The fire event in NAPS and its consequences were the result
systems for reactor protection remained disabled for nearly of lapses and oversights in several areas of its design,
19 hours of SBO duration. This event was marked by construction as well as in internal and regulatory reviews of
common cause failures of most safety systems and reactor this NPP unit. The comprehensive nature of technical and
protection systems, and showed weak safety culture as well administrative measures and changes in equipment by
as weak QA. As per INES, events showing any of these NPCIL after this fire accident indicate that these weaknesses
weaknesses should be marked one level above the basic were dormant in the design, construction, commissioning
level. Hence, this event should have been ranked as level 4 and operational processes for over a decade. These
on the INES scale. weaknesses had not been addressed adequately in internal
and regulatory reviews of the NAPS project, indicating slack
Observations and conclusions on review of Narora fire safety culture in the area of fire prevention and suppression.
event
In comparison of NAPS fire with fire events in other NPPs The location of hydrogen tank inside the turbine building
listed above, it is clear that the NAPS fire event was the was responsible for the intensity of the hydrogen combustion
most intense and severe. Only the fires in Chernobyl and (possibly explosion) as reported in reference [3]. It would
Fukushima events (both at level 7) were more severe than have been appropriate if the hydrogen tanks had been
the NAPS fire event. The Beloyarsk event listed showed located in separate rooms that are designed to withstand and
similar failures and consequential effects, though it did not suppress hydrogen fires. In addition, provisions for quick
involve fire in the turbine building. The events in Maanshan, isolation on the lines leading out of the hydrogen tanks
Vandelos and Salem involved turbine blades rupture and should be incorporated if abnormal low pressure is sensed in
consequential fires, though the consequential effects were the tank. It is not clear from reference [3] if these
not as severe as those in NAPS. However, fire control precautions had been taken. Extensive use of flammable
actions on NAPS, even though manual, were quicker than on insulation materials and filler materials for penetration joints
other reactor units. was the direct cause of loss of all sources of electric power
from class I to class IV i.e. beyond SBO event. Similarly,
This accident brought to light the strengths and weaknesses sharing of power and control cables in the same cable ducts
of Indian nuclear power program and its regulatory program also contributed to the beyond SBO accident. Either
for safety, at that time. The root cause of the fire, namely, evidence of weak safety culture or common cause failures
blade ruptures, and their effects, namely, hydrogen leaks causing the incident are grounds for increasing its INES
leading to detonation and fire propagation causing beyond level by 1. In order to provide assurance of safety in our
SBO conditions highlighted their weaknesses. The actions nuclear projects, it is recommended that the regulatory body
in manually activating the GRAB system, manually conduct safety audits during design, construction and
activating the steam relief actions, and in manual linking of commissioning to assure that its recommendations are being
external fire water supply to the steam generators acted upon. These safety audits should be complemented by
highlighted inherent strengths. inclusion of subject experts drawn from outside the
department of atomic energy. Likewise, whenever any event
The incorporation and testing of the GRAB system, and rated at first sight at level 3 or higher on the INES scale,
testing of the thermo-syphon system during commissioning opinion of subject experts drawn from outside the
was done at the instance of the regulatory body, showing its department of atomic energy should be sought and
effectiveness. considered when finalizing its level on the INES scale.
It is also noteworthy that the thermo-syphon mode of References
cooling was effective even with a diminishing heat sink in
form of shell-side water in the steam generators. This was [1] TECDOC-1112 Root Cause Analysis – Fire Events
possible since this mode of cooling, with healthy heat sink, [2] CEA/CNRA/R(2014)1 “FUKUSHIMA DAIICHI NPP
was designed and tested during commissioning, and PRECURSOR EVENTS”
sufficient margins of safety were demonstrated. These [3] NUREG/CR/6738 -Risks Method Insights From Fire
margins were depended upon when steam relief valves were Incidents
opened by operators for about 5 hours before portable fire [4] TECDOC-1421 –Experience gained from Fires in NPPs
water pumps could be aligned to the steam generators.
Aligning the portable fire pumps to the steam generators
Volume 8 Issue 10, October 2019
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Paper ID: ART20202268 10.21275/ART20202268 1716
