ML050840506
| ML050840506 | |
| Person / Time | |
|---|---|
| Site: | Point Beach  |
| Issue date: | 04/09/2004 |
| From: | Nuclear Management Co |
| To: | Office of Nuclear Reactor Regulation |
| References | |
| FOIA/PA-2004-0282 | |
| Download: ML050840506 (4) | |
Text
, Nuclear Management Company Pagel of4 1 State Change History
'd Initiate AR Pre-Screen Submit to Screening Team 4- AR Screening Que 0 4/9/2004 11:16:22 0 4/9/2004 13:23:05 by THOMAS, STU Owner (None) by STALZER, CHARLES l0Owner PBNP CAP Admin i!. .
8 Section 1 Activity Request Id: CAP055527 Activity Type: CAP Submit Date: 4/9/2004 11:16:22 t One Line
Description:
U1R28 Nozzle Dam Installation Supplied Breathing Air Problems i Detailed
Description:
4/9/2004 11:16:22 - THOMAS, STU:
During installation of Ul Nozzle dams on A and B SIG the following Breathing Air problems were encountered:
- 1. On the initial jump to B C/L SIG bowl the Scientech jumper experienced a loss of air. The individual exited the bowl and was immediately cut out of the bubble hood as expected. The individual showed no signs of distress. The job was stopped until we could ascertain the cause of the loss of air. OCC was informed that we would not restart the job until we found the cause. Based on reports from the RP techs and the individual we determined the cause to be insufficient air pressure and a pinched hose. I then authorized the job to restart.
- 2. An air line connection to the bubble hood became disconnected as a jumper was preparing to jump. The connection was remade up and again we stopped to determine why. The fitting was repeatedly challenged and then securely taped and then repeatedly challenged. This was repeated with all personnel In bubble hoods. The individual then jumped the bowl and completed the task.
- 3. It was later determined that an individual on the A side pinched their air hose under the temporary platform and cut the hose. They were not in the SIG. The personnel on the platform switched the hose to an undamaged hose.
4/11/2004 15:06:48 - THOMAS, STU:
Additional information was received by me during a debrief at approximately 0300,4/10/2004:
- 2 above: The individual was inside B SIG Cold leg when the air line became disconnected, the RPT was unable to reconnect the fitting and they did cut this individual out of the bubble hood.
- 3 above: The air line was partially cut by being pinched by the strong back. The hose was not leaking any air and the jumper never lost air to the bubble hood. Because the hose showed damage, the RP tech removed that hose and plugged the jumper into another hose.
- 4. An additional instance of an airline problem was relayed to me: A jumpers airline on A SIG became disconnected as the worker tried to enter the manway. The RP tech saw the connection hit the manway and disconnect. RP immediately reconnected the aiding and reconfigured it so it would not come in contact with the manway.
I am also attaching a statement made by Mark Peroutka, RP First Line Supervisor.
Initiator: THOMAS, STU Initiator Department: PR Radiation Protection PB Date/Time of Discovery: 4/9/2004 10:47:25 Date/Time of Occurrence: 4/9/2004 10:47:25 Identified By: Site-identified System: RC PB Equipment # (1st): (None) Equipment Type (1st): (None)
Equipment # (2nd): (None) Equipment Type (2nd): (None)
Equipment # (3rd): (None) Equipment Type (3rd): (None)
Site/Unit: Point Beach - Unit 1 Why did this occur?: 4/9/2004 11:16:22 - THOMAS, STU:
Three unique failures due to equipment, worker practices and oversight.
Immediate Action Taken: 4/9/2004 13:23:05 - STALZER, CHARLES:
None indicated by the author.
Recommendations: 4/9/2004 11:16:22 - THOMAS, STU:
Perform an ACE on these events.
0 Notify Me During Eval?: N g SRO Review Required?: N 83 Section 2
'Je- AZ http://enwsO2/tmtrackltmtrack.dll?lssuePage&Template=viewbody&recordid=594696&tab... 5/27/2004
Nuclear Management Company Page 2 of 4 Basis for Operability: 4/9/2004 13:23:05 - STALZER, CHARLES:
The CAP is documenting challenges experienced in nozzle dam installation and does not question plant equipment operability.
@Unplanned TSAC Entry:: N @ External Notification: N S Section 3 Screened?: Y @Significance Level: A INPO OE Reqd?: Y Potential MRFF?: N 0 QAJNuclear Oversight?: N i Licensing Review?: N Good CatchlWell Doc'd?: NA 1 Section 4 Inappropriate Action:
Process: (None) Activity: (None)
Human Error Type: (None) Human Perf Fail Mode: (None)
Equip Failure Mode: (None) Process Fail Mode: (None)
OrglMgt Failure Mode: (None) 0 Group Causing Prob: (None)
Hot Buttons: (None)
EDNotes/Comments Update to CAP 055527 by SHANNON, DAN (4/12/2004 1:57:53) [a The following update to CAP 055527 is provided based on followup discussions on 4/12/04 with the RPT who was present on the 1A S/G platform providing coverage for the 1A SIG nozzle dam installation on 4/9/04. These updates change the information provided in this CAP, the first update, and the attachment.
- 3 - Jumper on 1A SIG airline disconnected as worker tried to enter the SIG manway. RP tech saw the connection hit the manway and disconnect. The jumper was only halfway into the S/G bowl but was pulled back and then the RPT immediately reconnected the airline and reconfigured it so it would not come in contact with the manway.
- 4 - Jumper on 1A S/G damaged his airline when it became partially cut from being pinched by the strongback. Hose was leaking air, however, it was taped to control potential spread of contamination. The jumper was asked by the RPT if his air was OK and he replied it was OK several times. After this jump, the damaged hose was only used on the platform with an extra emergency hose on standby. As additional jumps were made, the hoses were switched between the jumper making the jump and those remaining on the platform.
1 Attachments and Parent/Child Links Mark Peroutka air line memo.doc (20992 bytes) by THOMAS, STU (4/11/2004 15:05:36)
E Princia__oCE000253: lR28Nozzle Dam Installation Supplied Breathing Air Problems by PFAFF, SCOTT (4/1212004 10:39:33) E3J Principa o OE057139: U1R28 Nozzle Dam Installation Supplied Breathinga Air Problems by KREIL, JULIE (4/20/2004 14:45:13) 1
'23Principal to CA057750: CATPR #2 from RCE253DevelopProcedure for Nozzle Dam Installation & RemovaI by KREIL, JULIE (5/2512004 8:25:26) 2 Principatto CA057751: CATPR #3 from RCE253-D-evelop-a Prcess to Dermin When HIT tams Project by KREIL, JULIE (5/25/2004 8:34:09)
Principal to CA057752: CA #1 from RCE253: Conduc Do umted BEefing forEgineerng by KREIL, http://enwsO2/tmtrackltmtrack.dll?lssuePage&Templateviewbody&recordid=594696&tab... 5/27/2004
Nuclear Management Company Page 3 of 4 JULIE (5125/2004 8:40:33) UJ et Principal to CA057753: CA #2 from RCE253: Conduct Documiente efin ction by KREIL, JULIE (5/25/2004 8:57:17) l ID PrincipaLto CA057754: CA #5 from RCE253: PreparQeExppctations and Brief Personnel on External OE by KREIL, JULIE (5/2512004 9:01:10) et3 Principal to C_7755: CA #6 from RCE253: Engineerin Proras CRC Perform Task Analysis by KREIL, JULIE (5/25/2004 9:04:31) 0 5 Principal to CA057756: CA #7 from RCE253: ConductDocumentedBjfngof Nuclear O esjghtPersonne by KREIL, JULIE (5/25/2004 9:08:47) i O Principalto CA57757: OTH #1 from RCE253: Create an It Can Happen Here Article by KREIL, JULIE (5125/2004 11:15:36) 0 S Principa to C 05_758: 0TH #2 from RCE253: Develop Industry OE on the Event by KREIL, JULIE (5/25/2004 11:18:00) 1i 4D Prncipa to CA057759: OTH #3 from RCE000253Perform I Nuc lear Safety Cultueessessment by KREIL, JULIE (5/25/2004 11:22:24) 0 3PrincipaltoCA57760:OTH#4from RCE000253:Develop na dssue Site Wide Communication on NP 1.1.7 by KREIL, JULIE (512512004 11:24:15) e3Principato*CA057761:0TH #5 from RCE000253 Review All Existing HighRisk Work Orders by KREIL, JULIE (5/25/2004 11:27:25) CD Principal togA057763: 0TH #6 from RCE000253: Take compped CRC Task Analysis From CA #6 to TOC by KREIL, JULIE (5/25/2004 11:36:14) fJ e9PrincipaltoEFR057765: EFR #1 fromRCE000253:PerformEffectiveness Review of CATPR #1 by KREIL, JULIE (5/25/2004 11:42:10) CD t3PrinCiplto FR057766: EFIR #2 from RCE000253: Perform an Effectiveness Review of CATPR #2 by KREIL, JULIE (5/25/2004 11:45:38) 0 e03Princi bto EFR057767:EFR#3fromRCE000253:PerformanEffectiveness ReviewofCATPR #3 by KREIL, JULIE (5/25/2004 11:48:33)
E Change History 5125/2004 11:36:14 by KREIL, JULIE Attachment Added: Principal to CA057763: OTH #6 from RCE000253: Take completed CRC Task Analysis From CA #6 to TOC 5125/2004 11:37:25 by KREIL, JULIE Last Modified Date Changed From .... *-- To *.......
5/25/2004 11:42:11 by KREIL, JULIE Last Modified Date Changed From *-...... To.*......
Attachment Added: Principal to EFR057765: EFR #1 from RCE000253: Perform Effectiveness Review of CATPR #1 http://enwsO2/tmtrack/tmtrack.dll?lssuePage&Template=viewbody&recordid=594696&tab... 5/27/2004
. -Nuclear Management Company Page 4 of 4 512512004 11:42:29 by KREIL, JULIE Last Modified Date Changed From ***-** To ...
5t2512004 11:45:38 by KREIL, JULIE Last Modified Date Changed From **..... To Attachment Added: Principal to EFR057766: EFR #2 from RCE000253: Perform an Effectiveness Review of CATPR #2 51251200411:46:00 by KREIL, JULIE Last Modified Date Changed From. *-*- To 5t251200411:48:33 by KREIL, JULIE Last Modified Date Changed From ***... To ...
Attachment Added: Principal to EFR057767: EFR #3 from RCE000253: Perform an Effectiveness Review of CATPR #3 http://enwsO2/tmtrack/tmtrack.dll?IssuePage&Template=viewbody&recordid=594696&tab... 5/27/2004