ML051470086

Pb Breaker Report. Attach: Undated Event Investigation Report CAP056776. Attach: Event Investigation Personnel Statement

ML051470086
Person / Time
Site:	Point Beach
Issue date:	05/24/2005
From:	- No Known Affiliation
To:	Office of Nuclear Reactor Regulation
References
CAP056776, FOIA/PA-2004-0282
Download: ML051470086 (4)

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Event Investigation Report Complete the evaluation of the human performance event using the following, as applicable:

1. Date and Time of the event: 5-17-04 2348hr CAP056776: 1X-04 Annunciator Alarm Activated by D52A Selector Switch Operation was initiated as a result of a selector switch manipulation bv Maintenance.

2. PersonneJnvolved: Chris Wienecke-EM Supervisor. Mike Heim- ENI Sunervisor.l ad ME and ME

3. Department/Group Involved: Maintenance / Electrical

4. Prograii/Work Process/ActivityInvolved: PMIWO 0301793Breaker inspection on H52-HK-2000-02 in the 13.8 bldg.

5. Unit: PBNP Unit 0

6. Mode/Powcr Level: Ut in Mode 6. U2 Mode 3

7. Describe the inappropriate action and conditions that led up to the event. Consider the following in this description:

a. Was a conscious decision made or not made by the individual(s) involved?

There was a conscious decision made bv the Lead Mechanic-Electrician.

The Lead ME was in knowledge base to resolve the problem of not having power to the breaker test stand and cycled a disconnect D-52A that actually fed the D-52 Panel which feeds the test stand and other loads.

b. Was the event a result of rule non-compliance, misapplication of a rule, or applying an incorrect rule? Yes, The Lead ME caused the event by not complvintz with the rule that only Operations can manipulate breakerstdisconnects unless controlled by a procedure or danger tag series.

c. Was the individual fully trained/knowledgeable of the task? Yes

d. Did the individual make an error in judgment?-Yes

c. Was ain intended action not performed due to shortcuts taken or inadequate tracking? Yes, the Lead ME took a shortcut by not "Stopping When Unsure".

f. Was the individual overconfident or was their mental/physical state a factor?

In his statement the Lead ME acknowledged he was feeling fatigued.

g. Did the supervisor not identify error likely situations and error precursors?

The Supervisor did not conduct a formal Pre-job brief and allo-wed the Lead ME to brief himself.

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h. Was there a process or organizational failure that led to this error (see table on next page)?

No Process Failure contributed to this event. Inadequate Communication within an Organization was the Organizational Failure Mode, due to lack of a formal pre-jo brief

8. Summarize the inappropriate action in one sentence as follows:

(Lead IME. opened the Power transfer switch to the D-52 panel instead of Gtipping When Unsure per PBNP managements expectation.

9. Based on what you have learned, describe the error likely situations that were prsent at the time of the event. The ME Lead did not receive a formal pre-brief and did not recognize when he was in knowledge base.

a. What Error Reduction Tools were not used or not used effectively? What Error Reduction Tools could have been used to prevent this event? Clearly statc which is the one tool, which if used, would have had the greatest chance of being successful.

-STAR, "ARE YOU READY CHECKLIST?" STOP WHEN UNSURE.

"Stop When Unsure" would have had the greatest chance of being successful.

b. Are these Error Reduction Tools going to provide the barriers to prevent recurrence? Where else should these barriers be applied?

Yes, provided thev are used appropriately. These barriers should be applied performing any task.

Human Performance Failure Modes (From the NMC Trend Code Manual)

S Inattention S Bored Distracted & Interrupted S Multi-Tasking Time & Schedule Pressure S Fear of Failure Spatial Disorientation S Mindset/Preconceived Idea Inadequate Motivation S Shortcuts Taken a Unfamiliar or Infrequent Task S Misdiagnosis 0 Inadequate Knowledge of Standards S Flawed Analytical Process or Model 0 Inadequate Knowledge of Fundamentals S Over Confident 6 Inadequate Verification S Cognitive Overload 0 Inadequate Tracking (Place Keeping) S Tired & Fatigued 0 Habit/Reflex S Lapse of Memory S Imprecise Communication S Wrong Assumptions S Work Around a Tunnel Vision

Event Investigation Personnel Statement Name: Chris Wienecke Position: Maintenance FLS Event Date: 5-17-04 Handwritten statements are acceptable. Include the plant conditions prior to the event, your indications that a problem existed, your action as a result of those indications, noted equipment malfunctions or inadequacies, and any identified .procedure deficiencies.

Also, include any information you consider important to the review of this event and actions that may prevent recurrence. Use additional paper as necessary.

I assignecg lhe breaker inspection job; ask him to review the package talked to him about wvhat e wcre going to do with this package and how we were going to do the task iMako discussed the possible need to go to training to get the M&TE for this job then asked _jo get the equipment needed for the task at hand. I handed out other jobs. I then inform the others suirxjors that we change so of the job assignments to incorporate other priorities. I also toldA_ jhat I wvould talk to Dave Schutte to find out wvhether or not training still had the MI TE over in training or did there return it? I also asked Dave Schutte to please get the latest revision on the TPE for under-voltage testing that was also schedule for us to do. I then directed my attention to other jobs and tasks. Mike Heim and myself were talking about the jobs and Mike saw that I had other tass at I Was doing and volunteered to help with the OCC approval paperwork. Mike asked Jhe questions so that he could fill out t frorm on that activity. Whe the coax of thafTorm came back Mike gave it tj jsince he would be helpingj When brief the job himself and wt hen to trt job site and pull the breaker out and set up his ools. I then received a call that ve shouldn't get started on the breaker inspection because of the risk being to high due to the G-O5 being in question. I then beepC. - *nto call my phone, which was. done within a couple of minutes? I askedf 3hether or n toeie breaker was still in the cubicle. His response wvas that it was already removed from the cubicle but that was all. I then told him that the job was on hold for now, but don't put up the M&TE and that I would get back with him. Mean time the D-08 ground came in and I directed my attention towards supporting finding the ground and getting that started, than got a beep from OCC that we can start back on the breaker PM, I then call OPS to verify that we can resume on the PMI for the breaker in cubicle I-a-HK-2000-02 the response was that we could resum lhe PM.

At that point and time a call and told him that we can resume, therefor4 Then removed the breaker again and star e the PM once again. Later OPS over the page s3stem paged "Andy Paulin call the control room" I then started walking to the under-voltage relay testing to find out what was going on met them halfway they told me that the job was stop until we know what happen. I then received a page to call the control room, I then called and talked to Ron Harper which told me that they lost indication for some of the 13.8 breaker and asked if I can come to the control room to find out what was wrong I reply that I wanted to go by the 13.8 bldg first and then come by, He said that would be fine. So I did,

I look for any thing abnormal and askeC Tjr anything unusual happen there response was nothing was unusual. I then when to t~control room they filled me in on what they encountered it was determined base on the facts that we lost D-52 for about two minutes. I then went back to my desk and pulled some prints to try to rind out what happen.

I then walked out to D-52 to look at It closer. I then received a call from OPS that directed us to stop work on the breaker until we found out what went wrong, I got to the 13.8 bldg and started to ask some question and found out that we haven even hooked up to the test stand before the problem accorded. I then call Ron Harper and told him of the information that I received and asked him if we don't hook up to the test stand can we resume the PM on the breaker. He said that we could af4 r we all fill out a statement on what we were doing at the time of the lost of the D-52. I toll Land Ron Ferrence (QC) I asked a fewt more questions thenr I-as telling what he diand he mention the he had a problem with the test stand and said dtat he cycled the disconnect D-52A at that point I told him that D-52A is what feeds D-s2 and that is why we lost power, he then realized that he did made a mistake. We then informed operations what happen and that it was a human error that took place, and that we were going to fill out the Human Pcrformance Event Investigation Tool form. Operation called me again to inform me that they wanted to talk to the two technicans, I told them that we would meet them in my cubical. Operation met us there and they wanted to know if the technicians knew that they down powered D-52 when they asked them earlier, the answer was no that they didn't know until I told them.