05000370/LER-1993-005
| ML20056H211 | |
| Person / Time | |
|---|---|
| Site: | Mcguire |
| Issue date: | 08/30/1993 |
| From: | Mcmeekin T, Pedersen T DUKE POWER CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LER-93-005-03, LER-93-5-3, NUDOCS 9309090003 | |
| Download: ML20056H211 (10) | |
| Event date: | |
|---|---|
| Report date: | |
| 3702093005R00 - NRC Website | |
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thke Ibuw:r Company (704)S75-4033 McGwre Nuclear Stautm !
. 12 Calkem ikery Road !
Ilucersnile. hC28018 E%5 e i
DUKE POWER I
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August 30, 1993 t U.S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555 !
Subject:
McGuire Nuclear Station Unit 2 Docket No. 50-370 :
Licensee Event Report 370/93-05 !
Problem Investigation Process No.: 2-M93-0710 ;
Gentlemen:
Pursuant to 10 CFR 50.73 Sections (a) (1) and (d), attached is l Licensee Event Report 370/93-05 concerning an initiation _of a black out signal resulting in an Emergency Safety Features actuation !
resulting from an inappropriate action. This report is being !
eubmitted in accordance with 10 CFR 50.73 (a) (2) (iv). This event is l considered to be of no significance with respect to the health and ;
safety of the public.
Very truly yours,
)) McMeekin T.C.
TLP/bcb ,
Attachment xc: Mr. S.D. Ebneter INPO Records Center Administrator, Region II Suite 1500 .
U.S. Nuclear Regulatory Commission 1100 circle 75 Parkway 101 Marietta St., NW, Suite 2900 Atlanta, GA 30339 ,
Atlanta, GA 30323 i
Mr. Victor Nerses Mr. George Maxwell U.S. Nuclear Regulatory Commission NRC Resident Inspector Office of Nuclear Reactor Regulation McGuire Nuclear Station j Washington, D.C. 20555 r 93090idOd3'f3'OB30 PDR 7 l S ADOCK 05000370 h < '
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+ 1 bxc: B.L. Walsh R.C. Futrell (CNS) l P.R. Herran l
!- R.C. Norcutt M.E. Patrick (ONS)
G.H. Savage G.B. Swindlehurst '
H.B. Tucker .
l R.F. Cole [
D.B.
G.A.
Cook Copp C.A. Paton {
M.E. Pacetti P.M. Abraham W.M. Griffin !
NSRB Support Staff (EC 12-A) l I i (
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ti l Duke hous'r Company (IO4)RIS 4000 AfcGwre Nuclear Statwn 12700 flagers ferry Road fluntersnile, NC280Tb-h9h5 DUKE POWER August 30, 1993 U.S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555
Subject:
McGuire Nuclear Station Unit 2 Docket No. 50-370 Licensee Event Report 370/93-05 Problem Investigation Process No.: 2-M93-0710 Gentlemen:
Pursuant to 10 CFR 50.73 Sections (a) (1) and (d), attached is Licensee Event Report 370/93-05 concerning an initiation of a black out signal resulting in an Emergency Safety Features actuation resulting from an inappropriate action. This report is being submitted in accordance with 10 CFR 50.73 (a) (2) (iv). This event is considered to be of no significance with respect to the health and Safety of the publiC.
Very truly yours, T.C. McMeekin TLP/bcb Attachment xc: Mr. S.D. Ebneter INPO Records Center Administrator, Region II -
Suite 1500 U.S. Nuclear Regulatory qpmmission 1100 circle 75 Parkway 101 Marietta St., NW, Suite 2900 Atlanta, GA 30339 Atlanta, GA 30323 Mr. Victor Nerses Mr. George Maxwell U.S. Nuclear Regulatory Commission NRC Resident Inspector Office ci Nuclear Reactor Regulation McGuire Nuclear Station Washington, D.C. 20555
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. I bxc: B.L. Walsh R.C. Futrell (CNS)
P.R. Herran {
R.C. Norcutt I M.E. Patrick (ONS) I G.H. Savage i G.B. Swindlehurst I H.B. Tucker i R.F. Cole !
D.B. Cook f G.A. Copp l C.A. Paton l M.E. Pacetti l P.M. Abraham -
W.M. Griffin NSRB Support Staff (EC 12-A) l 1
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LICENSEE EVENT REPORT (LER)
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FACILITY NAME(1) IOC7Et NtMBER(2) PACEf3) ;
McGuire Nuclear Station, Unit 2 05000 370 3 OF 6 l Tm.E(4 ) Initiation Of A Blackout Signal Resulting In An Emergency Safety Features Actuation l Resulting From An Inappropriate Action.
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ITElrT DATFf5) IJ:R fatMHGf h) KrPORT DATE(7) (YMfrR F ACILITIES INVOLVEDfD) I MONTH DAY YEAR YEAR SEQUEFTTIAL REVISION M3 NTH DAY YEAR FACIIITY NAwfS DOCKIT F'JMBEPf S)
NuxsEn NuM8En 05000 1 07 31 93 93 05 0 08 30 93 05000 OPERATING 0 Tnts arPORT s r.unMITrED roRsuANT vo RrouiREMENTs or toCrR (chwk one or enre or tha fo12n-snr2)(11)
N DE(9) 70.402(b) 20.405(c) X 50.73(a)(2)(iv) 73.71(b) 1"OWER O r,r 20.405(a)(1)(1) 50.36(c)(1) 50.73(a)(2)(v) 73.72(e) f LEVEL (10) 20.405(e)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) OTHER l (Specify in 20.405(a)(1)(111) 50.73(a)(2)(1) 50.73(a)(2)(v111)(A) Abstract below t and in Text) -
20.405(a)(1)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) 20.405(a)(1)(v) 50.73(a)(2)(111) 50.73(a)(2)(x)
LICrNSEE CONTACT Fuu 'n:Is LER(1s }
EAME Tf1EPHONE NUMBER Terry L. Pedersen, Manager, Safety Review Group AREA cone ,
704 875-4487 I CCHPLPTE ONE LINE POH FACH (I]MPONENT P AIIMRE DESCRIHED IN THIS HEPolff(13) ,
CAUEE SYS*EM COMPONENT MANUFACTURER RF#ORTABLE CAUSE SYSTEM COMPONENT MANUTA0TURER REPORTABLE W h7ms M ATES ,
NO mTPrLD w>fTAL REPORT FXPECTED(14) EXPECTED MONTH EAY YEAR ,
SUBMISSION YES (If yen, complete EXPECTED SUBMISSION DATE) X No DATEf15)
ABSTRACT (Limit to 14D0 spaces, i.e. approximately fifteen single-epace typewritten lines (16)
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On July 27, 1993, Operations (Ops) personnel attempted to reinstall a potential transformer j (PT) fuse associated with the Unit 2 Train B 4.16KV Emergency Power Source. While trying to install the fuse it broke and a replacement fuse was not available. A decision was made to i subetitute a 1 Amp fuse in the interim for the required .5 Amp fuse to facilitate Diesel Generator break-in runs. Work Order (WO) 93053534 was written to get the 1 Amp fuse installed and hcve it replaced with the correct size fuse when received. When the correct ,
size fuee was received, ops personnel replaced it. While trying to complete the WO, the Instrumentation and Electrical Maintenance (IAE) Supervisor discovered the need for a Quality Control (QC) inspection. A Senior Reactot Operator (SPO), the IAE Supervisor, and a QC l Inspector went to check the fuse and per[orm the required inspections. The SRO opened the t
wrong PT compartment simulating a Blackout signal thus initiating a Load Sequencer actuation. ,
Unit 2 was in No Mode (all fuel removed from the core) at the time of this event. This event is assigned a cause of Inappropriate Action. This was due to Failure to Adhere to Policies, Directives, or Management Procedures and Lack of Attention to Detail. Corrective Actions include revising the drawings to cl m rly indicate the PT's location, installing better labels ,
on the compartments, communicating the event to Station Personnel emphasizing the need for '
Self Verification and good communication, and defining the roles of Ops and IAE as it relates i to operations versus maintenance, l
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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION PAcIL2;r EAne(2), Docrrt NUMEER(2) LER h*JMBER(6) PAGE(3)
( YEAR SEQUEN;1AL REVISION l wuxnEn wuxara l I l l McGuire Nuclear Station, Unit 1 05000 369 93 04 0 2 w 6 l l l
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i EVALUATION: l Br.ckground The Diesel Generator Auxiliary Power (EPQ) system [EIIS:EJ) and Diesel Generator Load Sequencer [EIIS:EK) function to energize the necessary Engineered Safety Features (ESF) J loads in a prescribed sequence and in such a manner that the Diesel Generator (DG)
{EIIS:DG) or the Auxiliary Transformers [EIIS:TD) are not momentarily overloaded. This is accomplished by a number of timers [EIIS TMR) which coordinate the load applications on l the DG or Auxiliary Transformers as required. When normal power is lost to the Essential Auxiliary Power (EPC) system [EIIS:EB) bus, all loads and feeder [EIIS FDR] breakers
[EIIS52] will be automatically disconnected and reconnected to their respective essential )
bus by the Load Sequencer. ;
1 The 4160 Volt EPC system distributes essential power, either directly at 4160 volts or transformed to lower voltages, to nuclear safety related auxiliary equipment required to maintain safe Reactor [EIIS RCT) status during all modes of plant operations, including a Safety Injection concurrent with a Blackout, or Blackout Conditions. .
Description of Event On July 15, 1993, Operations (Ops) personnel tagged out the Unit 2 Train B Emergency l Diesel Generator (2B DG) for routine outage maintenance. This was done in accordance with Operations Management Procedure 2-17, Tagout/ Removal and Restoration (R&R) Procedure, and listed in the Technical Specification Action Item Logbook (TSAIL). After completion of the maintenance work, Maintenance personnel n'eeded to have the 2B DG capable of being i loaded to facilitate completion of the break-in runs. During this period the 2B DG would l be run for short periods of time and readings taken to ensure there were no problems with 1 n ,
it prior to any testing to determine operability. 1
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1 On July 27, 1993, Opn personnel went to reinstall the fuses located in the Potential l
Transformer (PT) circuit associated with the 2B DG Breaker. While attempting to insert l i
the fuse in the fu! e holder, one of the fuses broke. Ops staff was notified and they l discovered that a replacement fuse was not available on site. Engineering personnel were consulted to see if a substitute fuse could be found and used in the interim to facilitate l l
the break-in runs. Engineering personnel evaluated the use of a 1 Amp fuse and determined <
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that there would be no problem as long as it was changed out prior to final testing and i return of the 2B DG to service (declared operable).
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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION !
I NLLMT KW.F,(1) DOCEET NUMEER(2) 1.ER NUM!tR( 6 ) I'ACEf 3) [
YEAR SEQUENr2AI, EDf253 ON j WNJsEP WNJtER i
McGuire Nuclear Station, Unit 1 05000 369 93 04 0 3 or 6 f
Work Order (WO) 93053534 was written to get the 1 Amp fuse out of the warehouse and get it installed in the PT. A step was also included on the WO to replace the I Amp fuse with the .5 Amp fuse when it was received. The WO was planned for Instrumentation and
- Electrical Maintenance (IAE) personnel to perform the work using procedure IP/0/A/3090/02, Instrument and Electrical Troubleshooting. Ops, IAE, and Engineering personnel took one ,
of the good fuses from the PT to the warehouse to verify the 1 Amp fuse did in fact have l the same dimensions. After verifying the dimensions, ops personnel logged the wo into the '
TSAIL for 2B DG and took the 1 Amp fuse down to the 4.16KV switchgear and installed it in I the PT. At this time they signed off R&R 23-316. This allowed the DG break-in runs to be performed.
i on July 28, 1993, the .5 Amp fuse was received in the warehouse and checked out by IAE personnel. The fuse was given to Ops personnel for installation in the PT. There was no discussion as to whether or not there were any procedures or inspections required to complete the Wo. Ops personnel went down to the 4.16KV switchgear and replaced the 1 Amp fuse with the .5 Amp fuse. Once the fuse was replaced, Ops personnel proceeded with the 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> run required by Technical Specifications. When the IAE Supervisor reviewed the WO, it was discovered that a Quality Control (QC) inspection was required. Ops personnel were contacted to determine when the inspection could be performed. The IAE Supervisor was told that the 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> run would have to be finished prior to pulling the PT's to allow for the inspection. :
On July 31, 1993, the IAE Supervisor contacted the Shift Supervisor (SS) to get the PT's pulled to allow the QC Inspector to inspect the fuses. The 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> run had been completed .
and an inspection window was available. The SS reviewed the work to be performed and f assigned a Senior Reactor Operator (SRO) to go down to the 4.16KV switchgear with the IAE Supervisor and the QC Inspector. At this point the SRO felt he knew where the PT fuses were and felt comfortable with the work to be performed. The fact that the IAE Supervisor I responsible for the DG maintenance was accompanying him gave him another level of l'
confidence in their ability to perform the assigned task. He was not aware that the IAE Supervisor did not know where the fuses [were because IAE personnel did not normally have a Y
need to see these fuses. j WO 93053534, Task 2, stated: " REPLACE FUSE IN 4160 VOLT SOURCE POT TRANSFORMER IN 2ETB-3 l MODEL #9F60BBD905 GE TYPE EJ-I SIZE I 550KV .5E AMP 60 HZ MCM 2312.02-0059 004." There are two PT's in 2ETB-3 (Unit 2, 4.16KV Switchgear, Compartment 3). The 2B DG Breaker PT is located in the rear of 2ETB-3. The 4.16KV Switchgear Bus PT is located in the front of 2ETB-3. The one-line drawing does not indicate which PT is in the front and which one is in the rear. The SRO went to the front of 2ETB-3 and opened the compartment door. This revealed the drawer containing the PT's associated with the switchgear bus. A label on the drawer reads "2ETB BUS PT FUSES." An additional orange sticker reads " BUS POTENTIAL
LICENSEE EVENT REPORT (LER) TEXT CX)NTINUATION l
FAGILITY KAMf (1) IXXIET NUMiiEP(2) LER NUMBERf6) I' AGE (3) P YEAR SEQUENTIAL REVISION l NUw.BER WUMILER McGuire Nuclear Station, Unit 1 05000 369 93 04 0 4 or 6 ,
u TRANS." The SRO failed to notice the difference between the task description on the WO and the labels on the drawer and assumed these were the right ones. Unfortunately, the IAE Supervisor did not read the labels on the drawer and did not know that the right PT's ,
were located in the rear of the compartment.
l When the SRO opened the PT drawer a Blackout signal was sent to the Load Sequencer and subsequently started the process of shedding load from the 4.16KV Train B Essential Bus.
The DG did not start, nor were several bus loads actuated due to the fact that they were ,
isolated for maintenance work. All systems that were available, operated as expected which included a Train 'B', Nuclear Service Water (RN) [EIIS:BI) System, Blackout !
alignment for both units. Unit 1 was in Mode 1 (Power Operation), at 100% power. This RN ;
transient was handled well by Ops personnel with no consequential plant interruption.
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When the Load Sequencer started opening breakers, including the normal incoming breaker to i 2ETB, the SRO and IAE Supervisor knew immediately what had happened. They then reclosed ;
the PT drawer. When additional SRO's arrived, they went to the rear of 2ETB-3 and pulled l the correct PT's. The QC Inspector verified the fuse and the documentation was completed.
1 Conclusion [
This event is assigned a cause of Inappropriate Action. This was due to Failure to Adhere to Policies, Directives, or Management Procedures and Lack of Attention to Detail. The
, Failure to Adhere to Policies, Directives, or Management Procedures occurred when the .5 Amp fuse was installed on July 28, 1993. Ops personnel should have been working in I conjunction with IAE personnel and using the associated procedure. The WO was planned for IAE personnel to perform the replacement using procedure IP/0/A/3090/02, Instrument and I Electrical Troubleshooting. The actual installation of the fuse into the PT fuse holder, could have been performed by Ops personnel; however, IAE personnel should have documented I the installation on procedure IP/O/A/3090/02 and called for the required QC inspection.
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If this had been done, there would have been no reason for the SRO and IAE Supervisor to I have gone back to the switchgear on July 31, 1993, and therefore, the wrong PT would not j have been pulled. #
- This particular event is unique in that it involved replacement of a fuse by IAE personnel that is normally removed and reinstalled by Ops personnel. This overlap of Ops activities with IAE WO/ procedures, and the confusion of the procedural requirements of operations versus maintenance, contributed to this event. Interviews with both parties revealed their clear understanding of the station's policy on procedure adherence.
The Lack of Attention to Detail is attributed to the fact that the wrong PT was pulled.
The labels on the PT compartment in the front of 2ETB-3 clearly indicate that these PT's
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- . , j LICENSEE EUENT REPORT (LER) TEXT CONTINUATION I
FACLLirY M E(1) tr.ryr; FUMEER(7) LER prJME EP ( 6 ) FAGE(3)
YLAR SE(NENTIAL Frv1SION wuxnrp ww.9ER ,
McGuire Nuclear Station, Unit 1 05000 369 93 04 0 5 or 6 i
are related to the switchgear bus. The SRO should have compared the labels on the compartment door with the WO and obtained clarification when he discovered a mismatch in the description of the WO (Source Pot Transformer), and the label on the compartment door ;
(Bus PT Fuses / Bus Potential Transformer).
f A review of the Operating Experience Program (OEP) database for the twenty-four months prior to this event revealed no events as a result of Failure to Adhere to Policies, !
Directives, or Management Procedures. However, there were two McGuire Licensee Event Reports (LERs) associated with the inadvertent ESF actuation of the Load Sequencer resulting from an Improper or Inadvertent Action by Ops and/or IAE personnel. These events were documented on LERs 370/92-01, and 370/92-02. Since these two events involved the same equipment, same group (s), and came cause as the one described in this LER; this event is considered recurring. In both caces the corrective actions taken to proclude recurrence were specific to the event and would not have prevented this event.
This event is not Nuclear Plant Reliability Data System (NPRDS) reportable.
There were no personnel injuries, radiation overexposures, or uncontrolled releases of radioactive material resulting from this event.
CORRECTIVE ACTIONS:
Immediate: 1) The SRO at 2ETB-3 closed the Bus Potential Transformer Compartment.
- 2) ops Control Room Personnel implemented AP/2/A/5500/07, Loss of Electrical Power, and returned the Train B, 4.16KV switchgear to its pre-event status.
Subsequent: 1) None i
Plannod: 1) Engineering personnel will revise the one-line drawing for the Unit 1 l and Unit 2, 4.16KV switchgear to clearly indicate the location of the PT's.
- 2) ops Personnel will have labels installed on the Unit 1 and Unit 2, 4.16KV Switchgears to better identify the location of the PT's and possibility of causing a Blackout.
- 3) Site Communications personnel will communicate this event to Station Management Supervisors, to be shared in team meetings. The importance of Self Verification (STAR) and effective communication of work to be
j LICENSEE EVENT REPORT (LER) TEXT CONTINUATION TACM,IrY M (1) , DOCTET NUMBER (2) LER NUMBEP(6) FACE (3)
YEAR SEQUENTIAL REVISION NUMBER NUMBER McGuire Nuclear Station, Unit 1 05000 369 93 04 0 6 or 6 l
performed (written and verbal) will be stressed.
- 4) IAE and Ops personnel define and communicate the roles of each group as I it relates to operation versus maintenance, and the association of each with the QA Program.
1 SAFETY ANALYSIS:
Unit 2 was in No Mode at the time of the inadvertent ESF actuation. The ESF equipment I does not serve to mitigate the consequences of an accident with the unit in No Mode; therefore, the ESF actuation system [EIIS:JS) was not required to be operable. Some ESF 5 equipment (Auxiliary Feedwater, Turbine [EIlS:TRB) Driven Pumps, Safety Injection i
[EIIS:BQ) Pump, Centrifugal Charging [EIIS:CB) Pump, etc.) is intentionally removed from service to preclude damage to the equipment or the unit because the ESF equipment is not i designed to operate in No Mode. There were no operational problems, disturbances, or 1 i
damage to Unit 2 as a result of this event. t Unit I was in Mode 1 at 100% at the time of this event. Due to the interconnection of the RN System, a Blackout of Unit 2 Train B causes a re-alignment of the Unit 1 RN Train B.
This re-alignment consists of swapping the suction and discharge of the Train B RN pump to the Stand-by Nuclear Service Water Pond and closing the cross connect between the Train A and Train B RN headers which isolates the essential headers from each other.
Diesel Generator 2A and its associated bus were operable and available for service if needed. There were no events or situations requiring it to operate.
OPS personnel took immediate action to reset 2B DG Load Sequencer, close the 4.16KV feeder breaker, and return the associated equipment to its original state.
The health and safety of the public were,not affected by this event.
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