IR 05000261/1993035
| ML14182A259 | |
| Person / Time | |
|---|---|
| Site: | Robinson  |
| Issue date: | 01/19/1994 |
| From: | Merschoff E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Dietz C CAROLINA POWER & LIGHT CO. |
| References | |
| NUDOCS 9402080044 | |
| Download: ML14182A259 (52) | |
Text
JAN 19 1994 Docket No.:
50-261 License No.: DPR-23 Carolina Power and Light Company ATTN:
Mr. C. R. Dietz Vice President H. B. Robinson Steam Electric Plant Unit 2 P. 0. Box 790 Hartsville, SC 29550-0790 Gentlemen:
SUBJECT:
ENFORCEMENT CONFERENCE SUMMARY (NRC INSPECTION REPORT NO. 50-261/93-35)
This refers to the Open Enforcement Conference held at our request on January 10, 1994. The issues discussed at this conference related to the degradation of both emergency diesel generators while the unit was operated at power between the dates of November 12, 1993, and November 17, 1993. A list of attendees and a copy of your handout are enclosed. We are continuing our review of these issues to determine the appropriate enforcement actio In accordance with Section 2.790 of the NRC's "Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Roo Should you have any questions regarding these arrangements, we will be pleased to discuss the
Sincerely, Ellis W. Merschoff, Director Division of Reactor Projects Enclosures:
1. List of Attendees 2. Licensee Slides cc w/encls:
M. P. Pearson Plant Manager H. B. Robinson Steam Electric Plant P. 0. Box 790 Hartsville, SC 29550 (cc w/encls cont'd - See page 2)
9402000044 940119 PDR ADOCK 05000261 P
Carolina Power and Light Company
(cc w/encls cont'd)
H. W. Habermeyer, J Vice President Nuclear Services Department Carolina Power & Light Company P. 0. Box 1551 - Mail 0HS7 Raleigh, NC 27602 W. Dorman, Acting Manager Regulatory Compliance H. B. Robinson Steam Electric Plant P. 0. Box 790 Hartsville, SC 29550 Max Batavia, Chief Bureau of Radiological Health Dept. of Health and Environmental Control 2600 Bull Street Columbia, SC 29201 Dayne H. Brown, Director Division of Radiation Protection N. C. Department of Environment, Commerce & Natural Resources P. 0. Box 27687 Raleigh, NC 27611-7687 H. Ray Starling Manager - Legal Department Carolina Power and Light C P. 0. Box 1551 Raleigh, NC 27602 Karen E. Long Assistant Attorney General State of North Carolina P. 0. Box 629 Raleigh, NC 27602 Robert P. Gruber Executive Director Public Staff - NCUC P. 0. Box 29520 Raleigh, NC 27626-0520 Public Service Commission State of South Carolina P. 0. Box 11649 Columbia, SCI 29211 bcc w/encls:
(See page 3)
Carolina Power and Light Company
JAN I 9 1994 bcc w/encls:
H. Christensen, RH B. Mozafari, NRR Document Control Desk NRC Resident Inspector U. S. Nuclear Regulatory Commission Route 5, Box 413 Hartsville, SC 29550 RII:DR RIrst
- DRP RII:DRP
- D M~are s:tj HC ristensen DV rrli JJo n
01/ J/94 01//2/94 01//2/94
/9
ENCLOSURE 1 Carolina Power and Light Company:
W. Orser, Executive Vice President C. Dietz, Vice President, Robinson M. Pearson, Plant General Manager, Robinson W. Robinson, Vice President, Harris G. Attarian, Chief Electrical Engineer W. Campbell, Vice President, Nuclear Engineering Department R. Barnett, Manager, Project Management D. Winters, Shift Supervisor, Robinson J. Guibert, Consultant P. Musser, Manager, Engineering and Technical Support, Robinson A. Carley, Manager, Communications, Robinson R. Stancil, Manager, Nuclear Business Planning and Analysis D. Davis, Consultant R. Rogan, Manager, Licensing Nuclear Requlatory Commission:
L. A. Reyes, Deputy Regional Administrator, Region II (RH)
J. R. Johnson, Deputy Director, Division of Reactor Projects (DRP), RII A. F. Gibson, Director, Division 'of Reactor Safety (DRS), RII J. P. Jaudon, Deputy Director, DRS, RH T. A. Peebles, Chief, Operations Branch, DRS, RH B. Uryc, Acting Director, Enforcement and Investigation Coordination Staff (EICS), RH S. S. Bajwa, Acting Director, Project Directorate II-1, Office of Nuclear Reactor Regulation (NRR)
D. M. Verrelli, Chief, Reactor Projects Branch 1, DRP, RH H. 0. Christensen, Chief, Reactor Projects Section 1A, DRP, RII C. F. Evans, Regional Counsel, RII J. Miyagawa, B. L. Mozafari, Project Manager, NRR W. T. Orders, Senior Resident Inspector - Robinson, DRP, RII L. J. Watson, Acting Senior Enforcement Specialist, EICS, RII P. J. Kang, Electrical Engineer, NRR J. L. Starefos, Project Engineer, DRP, RII Public Visitors:
E. Wallace, Veltra Tech, In S. Hobbs, GDS Association T. Lam, North Carolina State Utilities Commission
NRC Notice Of Enforcement Conference (December 10, 1993)
Cp&L Emergency Diesel Carolia Power & Light Generators Robinson Nuclear Plant January 10, 1994
Agenda Introduction W. S. Orser Sequence Of Events C. R. Dietz Root Cause Investigation W. R. Campbell And Corrective Actions Safety Significance W. R. Campbell CP&L Position C. R. Dietz Closing Remarks W. S. Orser CP&L Carolina Power & Light
Introduction CP&L Carolina Power & Light
Introduction Introduction
The Plant Was In A Degraded Condition During The S/U Period In Mid-November In That T.S. 3.7.1.d Was Not Me "A" Diesel Started But Failed To Achieve Rated Voltage
-
"B" Diesel Subsequently Failed To Start
Although The Plant Was In A Degraded Condition, There Was No Adverse Effect On The Health And Safety Of The Public
"A" Diesel Would Have Performed Its Specified Safety Function
The "B" Diesel Failure Mechanism Has Proven To Be Complex. Our Initial Corrective Actions Were Too Narrowly Focused And Caused Us To Address Symptoms Rather Than The Root Cause CP&L Carolina Power & Light
Introduction Introduction (Cont.)
- Subsequent Corrective Actions Have Been Comprehensive And Extensive
CP&L Believes These Actions Will Be Effective In Ensuring Reliable Diesel Performance In The Future
CP&L Will Discuss Several Broader Lessons Learned As A Result Of This Experience CP&L Carolina Power & Light
Sequence Of Events CP&L Carolina Power & Light
Sequence Of Events Oct 25 - Nov 12 (Pre-Startup Phase)
Key Points
Found Broken Springs In Air Start Distributor
Reasonable Actions Taken To Correct Items Identified During Troubleshooting
Plant Startup Was Based On Test Evidence of "B" Diesel Generator Operability
-
Four Successful Surveillance Test Starts (Oct 27, Oct 27, Oct 29, and Nov 8)
After Replacing Broken Springs CP&L Carolina Power & Light
Sequence Of Events Nov 17 - Dec 25 (Post Startup - Root Cause Analysis Phase)
Key Points
"A" Diesel Was Test Started, But Voltage Was Low
"B" Diesel Failed To Start During Test (Subsequently Determined To Have Low Voltage Also)
Low Voltage Settings Restored - Protective And Procedural Fixes Implemented
Extensive Efforts Expended To Determine Failure Mechanism And Root Cause Of Nov 22 Failure
Extensive Utilization Of Outside Expertise CP&L Carolina Power & Light
Sequence Of Events Nov 17 - Dec 25 (Post Startup - Root Cause Analysis Phase)( Con't)
Key Points (Con't)
11/22 "B" Diesel Failed To Start. Thought To Be Caused By Debris
12/7 "B" Diesel Started Successfully; However, A Broken ASD Spring Found
12/21 "B" Diesel ASD Replaced
Six Successful Test Starts Of "B" Diesel Generator During This Period CP&L Carolina Power & Light
Sequence Of Events Dec 26 (Unrelated Failure To Start)
Key Points
Failure To Start On Dec 26 Appears To Be Unrelated To Previous Air Start Distributor Failure
Additional Outside Expertise Obtained
Extensive Efforts Are Being Expended To Investigate This Failure
Reliability Runs Are In Progress And The Root Cause Investigation Is Concluding CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions
"A"/"B" Diesel Low Voltage Actions Taken
Voltages Adjusted To Proper Value
Evaluation Team Established
Engineering Evaluation Initiated
Cover And Graduated Scale Installed
Verification Of Proper Setting Added To Operator Logs
Independent Team Established To Determine Root Cause CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions
"A"/"B" Diesel Low Voltage Conclusions And Findings
Most Probable Cause Was Inadvertent Mispositioning Due To Painting Independent Team Verified Opportunities For Improvement
Control Of Work Activities In Safety Related Areas
Use Of Planned Work Tickets (Versus Generic Work Tickets)
Broad Evaluation Of Industry Operating Experience To Identify Prior Work Control Issues CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions
"A"/"B" Diesel Low Voltage Corrective Actions
Protective Cover Added
Graduated Scale Added To The Automatic Voltage Regulator Adjustment Potentiometer
Verification Of Proper Setting Added To Operator Logs
- Eliminated Use Of Generic Work Tickets Inside The Power Block
Reviewed The Scope Of Painting Activities To Verify Other Equipment Was Not Potentially Impacted CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions
"A"/"B" Diesel Low Voltage Corrective Actions (Con't)
Painting And Insulation Activities In The Power Block Are Now Governed By Specific Work Tickets. Cleaning Activities Are Being Administratively Controlled, With A Procedure Under Development - To Be Completed By April 1, 1994
An Engineering Evaluation Will Be Completed To Provide Justification For An Acceptable Voltage Tolerance Consistent With The Format Of The Standard Tech Specs (Which Provides A Tolerance of + /- 10%) - This Guidance Will Be Incorporated Into Operations Surveillance Procedures CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions
"B" Diesel Start Failures - Overview Current Status
Starting Air Distribution Problems
Start Failure Of December 26, 1993 CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions
"B" Diesel Start Failure Of Oct 25 Actions Taken
Troubleshooting Plan Developed With Vendor
Investigation Team Formed
PNSC Convened And Directed Disassembly Of The Air Start Distributor - Subsequently Discovered Three Broken Springs
Additional Efforts Initiated To Confirm Evaluation Of Spring Failure Mechanism CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions
"B" Diesel Start Failure Of Nov 22 Actions Taken
Troubleshooting Plan Developed
PNSC Directed The Establishment Of An Accelerated Test Program
Outside Assistance Obtained From The Vendor And From Brunswick And Harris Plants CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions Air Start Distributor Spring Failure Of Dec 7 Actions Taken
An Independent Team Was Formed To Challenge The Conclusions Drawn From The Oct 25 and Nov 22 Events
Additional Broken Spring Identified Due To Questioning Attitude On Part Of Operators During A PNSC-Mandated Surveillance Run
Broken Springs Sent To Metallurgical Lab For Analysis
New Air Start Distributor Ordered And Assistance Requested From FPI To Determine Root Cause CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions Conclusions And Findings
Failure Mechanism Has Been Determined To Be Binding Of The Air Start Distributor Pilot Valves Caused By A Combination Of Excessive Wear And Wear-Generated Foreign Material
The Root Cause Is Admission Of Starting Air To The Air Start Distributor With The Diesel At Operating Speed CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions Air Start Distributor Investigation Opportunities For Improvement
A More Thorough Evaluation Of The Condition Of The Air Pilot Valves, Air Distributor Housing, And Air Start Distributor Could Have Led To An Earlier Understanding Of Failure Mechanism
Need For A More Systematic, "Graded Approach" To Root Cause Analysis Activities Involving Dedicated, Multi Discipline Investigation Teams
Technical Experts Both Within And External To CP&L Could Have Been Solicited Earlier To Assist In Determination Of Root Cause CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions Air Start Distributor Investigation Corrective Actions
Air Start Distributor And Pilot Valves Replaced
Preventive Maintenance Task Initiated For Periodic Inspection/Cleaning
Instrumentation Added To Allow Identification Of Any Subsequent Inadvertent Pressurization
A Self-Assessment Of Current Root Cause Evaluation Procedures And Training For Technical And Maintenance Personnel Will Be Completed By April 1, 1994 CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions Unrelated "B" Diesel Start Failure Of Dec 26 Actions Taken
Diesel Quarantined, As-Left Condition Preserved
Dedicated Team Established
Additional Instrumentation Connected
Five Subsequent Starts To Attempt To Recreate The Problem
Outside Assistance Obtained (FPI/BNP/Tech Rep)
Inspection/Troubleshooting Plan Developed CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions
"B" Diesel Start Failure Of Dec 26 Conclusions And Findings
Could Not Repeat Failure
Believe Diesel Generator Did Roll On Starting Air, But May Have Been Slow Opportunities For Improvement
Need To Strengthen CP&L Review And Control Of Vendor Information
Pending Determination Of Probable Root Cause CP&L Carolina Power & Light
Root Cause Investigation And Corrective Actions
"B" Diesel Start Failure Of Dec 26 Corrective Actions
Additional Monitoring And Instrumentation
Reliability Demonstration Testing Program
Comprehensive Review Of Preventive Maintenance Scope And Frequency To Be Completed By April 1, 1994
NAD Assessment Of Procedures And Practices Used For Processing Of Vendor Information To Be Completed By February 21, 1994 CP&L Carolina Power & Light
Safety Significance CP&L Carolina Power & Light
Safety Significance
"A"/"B" Diesel Low Voltage
Design Basis
-
Each Emergency Diesel Generator Shall Be Designed With Sufficient Capability To Sequentially Start, Accelerate, And Provide The Electrical Power Requirements Of One Complete Set Of Safety-Related Equipment
Calculation Basis - Worst Case Scenario
-
Large Break LOCA WITH Loss of Off-site Power AND Failure Of One Diesel Generator
Conclusion
"A" Diesel Was Capable Of Performing Its Intended Safety Function CP&L Carolina Power & Light
Safety Significance
"B" Diesel Failures
Impact On IPE Core Damage Frequency Is Insignificant
Opposite Train Equipment Was Available While "B" Diesel Was Inoperable
Total Out-Of-Service Time Posed Low Risk
Dedicated Shutdown Diesel Available CP&L Carolina Power & Light
CP&L Position CP&L Carolina Power & Light
CP&L Position Low Voltage Setting
Plant Was In A Degraded Condition Per Tech Spec 3.7. Testing On Nov 22 Resulted In A Failure Of "A" Diesel To Achieve Rated Voltage (480V)
-
"B" Diesel Failed To Start
Subsequent Testing Of The "B" Diesel Identified A Similar Low Voltage Setting
Upon Determination Of The Low Voltage Condition
-
"A" Diesel Was Declared Inoperable
-
Voltage Was Adjusted
-
"A" Diesel Was Returned To Service CP&L Carolina Power & Light
CP&L Position Low Voltage Setting
Licensee Identification
-
The Low Voltage Settings Of Both Diesels Were Identified During Licensee Testing
Licensee Actions
-
Root Cause Was Determined (Exposure Of The Voltage Regulator Control Knob To Inadvertent Manipulation)
-
Appropriate And Timely Corrective Action Was Taken To Preclude Future Misadjustments CP&L Carolina Power & Light
CP&L Position Air Start Distributor Failures
Actions Following Oct 25 Failure Did Not Prevent Occurrence Of Related Failures
Initial Corrective Action Was Timely And Appropriate Based On Available Evidence
-
Four (4) Successful Start Tests Appeared To Affirm Problem Resolved (Although Specific Root Cause Not Identified)
Initial Efforts Were Narrowly Focused On The Symptom Instead Of Underlying Causes(s)
Complexity Of Distributor Failure Mechanisms Complicated The Initial Determination Of Root Cause CP&L Carolina Power & Light
CP&L Position Air Start Distributor Failures
Licensee Identification
-
The Failure Of "B" Diesel Was Identified During Licensee Surveillance Testing
-
There Had Been No Prior Opportunity To Identify Or Anticipate This Type Of Failure
Licensee Actions
-
Subsequent To The Related Failure On Nov 22, An Extensive Effort Was Expended To Determine The Failure Mechanisms And Root Cause
-
The Failure Mechanism Was Determined To Be Complex And Unlikely To Have Been Anticipated Or Avoided Based On Industry Or Plant Experience
-
Approach Was Conservative, Factually Based And Comprehensive CP&L Carolina Power & Light
CP&L Position Summary
The Plant Was In A Degraded Condition During The S/U Period In Mid-November In That T.S. 3.7.1.d Was Not Me "A" Diesel Started But Failed To Achieve Rated Voltage
-
"B" Diesel Subsequently Failed To Start
Although The Plant Was In A Degraded Condition, There Was No Adverse Effect On The Health And Safety Of The Public
-
"A" Diesel Would Have Performed Its Specified Safety Function
The "B" Diesel Failure Mechanism Has Proven To Be Complex. Our Initial Corrective Actions Were Too Narrowly Focused And Caused Us To Address Symptoms Rather Than The Root Cause CP&L Carolina Power & Light
CP&L Position Summary (Cont.)
- Subsequent Corrective Actions Have Been Comprehensive And Extensive
CP&L Believes These Actions Will Be Effective In Ensuring Reliable Diesel Performance In The Future
CP&L Has Recognized Several Broader Lessons Learned As A Result Of This Experience CP&L Carolina Power & Light
Closing Remarks CP&L Carolina Power & Light
Appendix Figures 1. Air Start System Flow Diagram 2. Air Distributor Air Start Pilot Valve Diesel Fuel Oil Supply Flow Diagram 5. "B" Diesel Fault Tree Summary Of Investigative And Corrective Actions Diesel Generator Timeline CP&L Carolina Power & Light
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Summary Of Investigative And Corrective Actions ("B" Diesel Unless Otherwise Noted)
Air System/Mechanical
Replaced Air Start Distributor (ASD)
Springs (Both Diesels)
Cleaned ASD Caps And Distributor
Replaced #5 Air Start (AS) Check Valve
Replaced Cam
Replaced ASD Springs #1, 5, and 6
Installed New ASD
Inspected, Tested, And Blew Down Air Pilot Lines
Blew Down AS Check Valve Header
Pulled And Tested All AS Check Valves
-
Replaced #1, 5
-
Lapped And Retested #2, 3, 4, 6 CPI&Llht
Summary Of Investigative And Corrective Actions ("B" Diesel Unless Otherwise Noted)
Air System/Mechanical (Con't)
Boroscope Inspection Of Three-Way Manifold
Inspected All Air Strainers
Observed Proper Operation Of Pilot Valves In Distributor
Pulled Lower Crankcase Covers On Pistons
- 2 And 5 To Inspect For Signs Of Overheating And Wear
Installed Temporary Instrumentation To Observe Starts
Summary Of Investigative And Corrective Actions ("B" Diesel Unless Otherwise Noted)
Fuel Oil System
Pressurized And Leak Checked With Black Light
Tested Unloading Valve
Tested And Replaced Orifice Check Valve
Tested And Replaced Check Valve Upstream Of FO Filters
Tested Priming Pump Check Valve
Tested Foot Valve
Replaced Governor
Sampled Both Fuel Oil And Lube Oil Cp&bIth
Summary Of Investigative And Corrective Actions ("B" Diesel Unless Otherwise Noted)
Electrical/Controls
Installed Scale Markings And Covers On Voltage Adjustment Knobs (Both Diesels)
Inspected Low Speed Sensor
Inspected Terminals And Wiring Of Starting Air Solenoid Circuit ClP&L'
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'B' Diesel Reliability Verification Program 10 Consecutive cold starts (Full monitoring and Instrumentation)
No Continue Successful?
troubleshooting and evaluation
' 0/6 Operable Yes Test diesel weekly until 10 additional successful starts are demonstrated 20 Consecutive No Continue starts troubleshooting and demonstrated?
evaluation Yes Return to normal T. S. test frequency with augmented mon itoring 59 Consecutive Continue starts troubleshooting and demonstrated?
evaluation Terminate augmented monitoring