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Category:- No Document Type Applies
MONTHYEARML20253A0092020-09-0202 September 2020
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Restated Articles of Incorporation Are Executed Pursuant to the Provisions of Section 32 of Chapter 64, Laws 1975, Being Section 51-26-7 N,M.S.A. 1953, as Amended
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Study Case 1986 MX-S3
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Prospectus, Employee Stock Purchase Plan of Southern California Edison Company
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FAQ 17-02: Palo Verde Unit 3 Scram (Final NRC Response)
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LTR-17-0038-1-Ticket - Roy Mathew, E-mail 2.206 Petition on Palo Verde Nuclear Generating Station, Unit 3 - Issuance of Amendment Nos. 199 and 200 Revision to Technical Specification 3.8.1, AC Alternating Current Source-Operating
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FOIA/PA-2015-0294 - Resp 2 - Final, Agency Records Subject to the Request Are Enclosed. Part 8 of 8
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FOIA/PA-2015-0294 - Resp 2 - Final, Agency Records Subject to the Request Are Enclosed. Part 7 of 8
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FOIA/PA-2015-0294 - Resp 2 - Final, Agency Records Subject to the Request Are Enclosed. Part 3 of 8
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Newspaper Notice, Exigent License Amendment Request to Amend Technical Specification Surveillance Requirement 3.1.5.3 for Control Element Assembly 88 for the Remainder of Cycle 19
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Attachment 2 - NRC Working Group Recommendations to Revise the Substantive Cross-Cutting Issue Process
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Attachment 1- NEI Comments on NRC Working Group Recommendations to Revise the Substantive Cross-Cutting Issue Process
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ROP Tabletop Examples and Results
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List of Historical Leaks and Spills at Us Commercial Nuclear Power Plants
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Safety Culture Policy Statement (Safety & Security) Comments
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Post Reg. Conference Reference Material - Simulator Review of JPM EP009-CR-001.
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Examples of Max Thermal Power License Conditions
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Preliminary Issue List, with Handwritten Notes
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Preliminary Issue List
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Table Titled Palo Verde Unit 2 - June 14, 2004 Loss of Offsite Power Event - June 25, 2004 (9:49)
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Fault Description Document
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2020-09-02
[Table view] |
Text
NRC URI's ERO ISSUES TITLE I DESCRIPTION:
TSC DIESEL FAILURE CORRECTIVE MAINTENANCE LEFT ONE OFTHE DIESEL GENERATOR CONTROLS IN AN ALLIGNMENT THAT PREVENTED THE DIESEL LOAD FUNCTION AFTER STARTING.
PUBLIC DISCUSSION:
NO APPARENT ROOT CAUSE:
THIS ISSUE WAS CAUSED BYA HUMAN ERROR-INATTENTION TO DETAIL. A PARTIAL RETEST OF THE TSC DIESEL GENERATOR HAD BEEN PREVIOUSLY PERFORMED, AS A PART OF CORRECTIVE MAINTENANCE ON THE STARTING BATTERIES. THE RETEST WAS DERIVED FROM MEMORY OF A REPETITIVE MAINTENANCE INSTRUCTION. THE TESTING UTILIZED "SKILL OF THE CRAFT" KNOWLEDGE, BUT WITHOUT WRITTEN INSTRUCTIONS AT THE WORK LOCATION. A CRITICAL POST-TEST ALLIGNMENT STEP WAS MISSED, (SETTING RUN-IDLE CONTROL SWITCH TO THE "RUN" POSITION). THIS CAUSED THE DIESEL TO ONLY ACHIEVE IDLE SPEED AFTER START, WITH A RESULTANT FAILURE TO ENERGIZE THE TSC EMERGENCY BUS. THE LACK OF BUS POWER IMPACTED THE COOLING SYSTEM FUNCTION OF THE TSC DIESEL, RESULTING IN SUBSEQUENT HIGH TEMPERATURE SHUTDOWN.
APPARENT CONTRIBUTING CAUSE:
- INADEQUATE WRITTEN WORK INSTRUCTIONS USED IN THE PERFORMANCE OF THE TSC DG RETEST AND ALIGNMENT.
- NO POST TEST, SECOND PARTY VERIFICATION OF THE AS-LEFT MACHINE ALLIGNMENT.
- NO COMPONENT MANIPULATION LOG IN USE, WHICH MAY HAVE PREVENTED THIS ERROR FROM REMAINING UNDETECTED EXTENT OF CONDITION:
THE EXTENT OF THIS CONDITION IS APPLICABLE TO THE TSC DIESEL THROUGH HUMAN ERROR. THE EMPLOYEE FAILED TO FOLLOW APPLICABLE GUIDANCE.
EFFECTIVE APPLICABLE GUIDANCE IS AVAILABLE FOR THE EMERGENCY DIESEL GENERATORS IN THE UNITS, THE ENGINE-DRIVEN FIRE PUMPS AND THE SECURITY DIESEL.
CORRECTIVE ACTIONS:
COMPLETED:
COACHING AND POSITIVE DISCIPLINE HAVE BEEN ADMINISTERED.
ONGOING:
a ADD TO BIANNUAL ELECTRICAL INDUSTRY EVENTS TRAINING.
Page 1 of 2
NRC URI's ERO ISSUES
- DEVELOP AN OPERATING PROCEDURE FOR THE STARTING OF THE TSC DIESEL GENERATOR FOR BOTH LOADED AND UNLOADED RUNS
- EVALUATE ADDING AN ALARM TO THE TSC ANNUNCIATOR PANEL TO WARN IF TSC DIESEL IS NOT ALIGNED FOR AUTO START/AUTO LOAD.
Page 2 of 2
