ML112220610
| ML112220610 | |
| Person / Time | |
|---|---|
| Site: | Prairie Island |
| Issue date: | 08/02/2002 |
| From: | Nuclear Management Co |
| To: | NRC/RGN-III |
| References | |
| EA-02-068 | |
| Download: ML112220610 (35) | |
Text
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Prairie Island Nuclear Generating Plant Pre-Decisional Enforcement Conference August 2, 2002 NMC)
!f-.--- _Agenda_.~_._._____.. _.. ~__.
- Introduction
- Factual Summary
- Lessons Learned
- Corrective Actions
- Conclusions NM~
__....~.~ct~aLSllJ)1mar____'1_
- Calvert Cliffs event review
- 06 operating and maintenance history prior to April 2001
- April 9 06 surveillance problems and NOEO request
- Events subsequent to April 16 grant of NOED
1996
- PINGP lube oils have Total Base Number(TBN) and sulfated ash properties similar to Calvert Cliffs
- No immediate action: fuel sulfur content high (0.18%), no scuffing noted during Preventive Maintenance (PM)
- Corrective actions: Discuss need to change oil with vendors, obtain recommendations for oil change by 1/1/97 to include in PM if required
- Nov 1996 - PINGP engineer attends SACM conference
- Summarized Calvert Cliffs experience as an "incompatibility between an entirely synthetic oil with a high TBN (> 15), high CD classification, and a low sulfur fuel"
- No problems with extensive use of mineral or synthetic lube oil and low sulfur fuel in Sweden, Germany, Switzerland & France
- SACM conclusion was "not enough experience" to "express formal statements about the lubricant-fuel influences"
.~~--~---~
NMC) 3
1996 - 1999
- Late 1996 - Mobil and SACM contacts
- Nov 1998 - 06 5-yr inspection and rebuild (530 hours0.00613 days <br />0.147 hours <br />8.763227e-4 weeks <br />2.01665e-4 months <br />)
- Some carbon buildup, rings move freely, no indications of blow-by
- BG&E experienced engineer involved
- Feb 1999 - PINGP attends SACM Owners Group meeting
- Calvert Cliffs solution included switch to mineral oil
- PINGP engineers report on high temperature in one 06 cylinder
- No linkage of 06 cylinder problem to oil incompatibility
- Nov 1999 - 06 24-hr load test completed successfully NM~
4
2000 - 2001
- Jan 2000 - Revised OE due date to Nov 2000
- Sulfur content dropping slowly, PINGP perceived that the industry and vendors did not agree with Calvert Cliffs root cause analysis
- May 2000 - 05 5-yr inspection and rebuild (450 hrs)
- No abnormal indications
- Jul 2000 - OE closed
- PINGP inspections of D5 and D6 found no ring problems, no scuffing, no blow-by, and "exceptional results" after 450 and 530 operating hours
- Calvert Cliffs reported hard deposits under rings, liner scuffing at 140-170 operating hours
Conclusions:
(1) Lube oil change not recommended; (2) Current performance monitoring and PMs adequate to identify condition
- Aug 2000 - Jan 2001
- Monthly surveillance runs and inspections satisfactory
- No data suggesting oil incompatibility NMC) 5
~u m ma~Y-l~96
~_~______
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- Complex technical issue, conflicting operating data
- Disagreement over Calvert Cliffs conclusion
- No evidence at PINGP after four years
- Continuing to look for indications
-\\
NM~
6
~_ Februar-y - April?~Q01
- Feb 2001 - Monthly run
- "Fuel oil" leak reported
- Mar 2001 - Monthly run
- Elevated crankcase pressure noted in log
- Apr 9, 2001 - Monthly run
- 0930 - entered TS LCO for 06 monthly run
- 1330 - terminated engine run -- elevated crankcase pressure
- 1500 - SACM recommends full borescope inspection
- 1526 - 05 Operability run
- Apr 10, 2001
- 1600 - Borescope identified bore polishing and blow-by on 06 E2-B1
- 1719 - Initiated a work order to repair D6
.:It:
NM~
7
,..----______1:)6 E2-B 1 H i~_~~ I~j_~_~'lY--a __ pr()~b ~em
- Sep 1997 D6 E2-B1 high exhaust temperature
- Feb 1998 Calibrated 06 E2-B1 exhaust temperature instrument - no change
- Feb 1999 Swapped 06 E2-B1/B5 fuel injection pumps
- Apr 1999 Returned 06 E2-B1/B5 fuel injection pumps
- SACM Unable to correct
- Apr 2001 Blow-by in same cylinder NMC>
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Draft NOED Pr~p_~_raJion_...____
- Apr 11, 2001
- Management considers contingency need for NOED to complete engine re-assembly Condition Report initiated to assess cylinder problem
- Apr 12, 2001
- Licensing prepares initial draft NOED following guidance in NRC Inspection Manual and previous PINGP NOED request
- Apr 13, 2001 0730 - SACM Tech Rep arrives to support re-assembly 1300 - OC reviews draft NOED, oil incompatibility not raised as issue 1400 - Draft NOED request faxed to NRC 1430 - Conference call with NRC Staff to discuss NOED NMC:>
"/
9
First Conference Call With NRC
- April 13, 2001
- PINGP participants
- Focus on PRA and compensatory measures
- Mr. Carlson substitutes for system engineering
- Site responded to NRC Staff questions
- History of D6 problem requiring NOED
- Apparent cause - high crankcase pressure from blow-by in a single cylinder Cause of blow-by not known No indication affecting other cylinders/other engines
- Collective engineering judgment: problem limited to E2-B1 Single problematic cylinder exhibiting limited blow-by
- No basis for tie to D5 or Calvert Cliffs
- Result of call
- Additional PRA information requested
- Follow-up callan April 16, 2001, to confirm need for NOED, PRA changes, NMC) 10
~_
Weekenq_t:!_~~~J~WQrk_______~____
- Apr 14, 2001
- 1308 - 06 reassembled
- 1835 - Start 06 break-in run
- Apr 15, 2001
- 0448 - Started 06 24-hr load test
- Apr 16, 2001
- 0449 - Completed 06 24-hr load test
- 0630 - OC meeting to approve NOED request
- 0730 - NRC conference call -- NOED verbal approval NM~
11
Second Conference Call
- April 16, 2001
- NOED needed - engine not re-assembled
- Revised PRA discussion per April 13 call
- NRC Staff verbally granted NOED
- 06 Successfully Completed 34 hours3.935185e-4 days <br />0.00944 hours <br />5.621693e-5 weeks <br />1.2937e-5 months <br /> of Operation
- Break-in period
- Load test
- No unusual operating parameters, no blow-by
- All indications were that problem limited to single cylinder NMC) 12
Context of the NOED
- Site experience supported preliminary conclusion of an isolated cylinder problem of unknown cause
- Focus was on problematic E2-81
- Available information did not point to oil incompatibility
- Single cylinder
- D5 apparently unaffected
- Did not find any "sticky rings"
- Questionable validity of Calvert Cliffs conclusion
- Different type of oil (mineral v. synthetic)
NMC) 13
Re~urn to O~erability "--"----------
Apr 16, 2001
- 0930 - NOED effective
- 1100 - Conference call with SACM (France)
Purpose to discuss engine condition Agreement on 12-hr run and borescope to confirm "break in" marks Many potential root causes discussed No root cause matched all PINGP conditions Oil incompatibility discussed -- SACM could not explain limitation of symptoms to a single cylinder
- 1300 - PINGP personnel and tech rep discuss status, pursue investigation
- Apr 17, 2001
- 0047 - Started D6 12-hr load test
- C/C pressure normal E2-B1 temperature w/in 50 degrees of others
- 1410 - Completed 06 12-hr load test
- 1500 - Performed borescope inspection - no degradation 1900 - Vendor representative concurrence with D6 condition
- 2331 - Completed TS required fast start test -- 06 declared operable NM~
14
Post-NOED Period
- Apr 18, 2001
- E-mail from engine vendor stating "suspect there could be incompatibility problem between fuel and lube oil"
- Root cause team forming to evaluate information
- Apr 23, 2001
- Requested Root Cause Report of Calvert Cliffs incident from BG&E
- Apr 30 - May 1, 2001
- Calvert Cliffs report received by PINGP engineer
- May 2,2001
- Calvert Cliffs report issued to Root Cause team
- May 9,2001
- D5 and 06 declared inoperable, Unit 2 shut down NMC>
15
Calvert Cliffs Root Cause Reoort
- First reviewed April 30 - May 2
- Identified technical parallels between events
- Problem initially found in one cylinder
- Established mineral - synthetic distinction not relevant to oil incompatibility issue
- Discussed independent analyses and unanimous conclusion of cause
- Provided root cause team with technical bases for oil incompatibility as the potential cause NMC) 16
Statement of Dennis Carlson
- No vendor recommended oil change
- No information indicated oil incompatibility in April 2001
- Limited role in 06 issue and NOEO
- Provided complete and accurate responses NMC) 17
Statement of Scott H iedeman
- Before reading the full Calvert Cliffs report had concluded oil incompatibility problem would not develop at PINGP because:
- Vendors did not recommend oil change and assured PINGP engines would not experience oil incompatibility
- PINGP used mineral-based rather than synthetic lube oil
- Absence of operating problems, especially during rebuilds
- Potential problems could be detected in preventive maintenance
- April 2001 incident was limited to a single cylinder NM~
18
StatemeoLof_S~9ttJ~iiedemClIl1 cont)
- The full Calvert Cliffs report changed view about the potential for an oil incompatibility problem:
- Realized SACM agreed oil incompatibility was root cause for Calvert Cliffs (contrary to statements made by SACM's U.S. representative)
- Realized symptoms of oil incompatibility could develop in a single cylinder
- Realized significance of "Total Base Number" NMC) 19
SIT Document Timeline
- May 14, 2001
- Document removed from SIT production stack
- Document later retrieved by concerned employee
- May 16, 2001
- Concerned employee determines document appears relevant
- May 17, 2001
- Document returned to NRC production process
- Document produced to SIT
- ECP investigation
- ECP manager informs SIT of investigation results and confirms SIT receipt of document
.. ~~
NM~
20
SIT Document Production
- Company Actions
- Promptly investigated individual's action
- Reported incident to SIT/Senior Resident
- Ensured SIT had document
Statement of Scott Hiedeman -- SIT
~,,----
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- Did not intend to mislead the NRC or withhold information
- Removed the Lube Notes article because thought it was inaccurate and misleading
- Removing the document was an error of judgment NMC) 22
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Lessons Learned
- Complacency
- Roles and responsibilities
- Lack of formal processes
- Management expectations, standards, accountabi I ities
- Quality validation/verification (QV&V) weaknesses
- Sense of ownership/urgency/follow-through NM~
25
OE Im~rQy~ments_~~_~_~~___
- Developed very comprehensive processes for review of external OE
- Assigned resources
- Integrated OE into our daily work
- Formed OE oversight process/team NM9
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EngineeriQA~Or~n_~zatiQn Improvements
- Role/responsibility changes
- Training improvements
- Formal turnover process
- Communication standards
- Organization changes NM~
27
N9ED R~~~est Pro~_e_s_s___~___
- Formalized Process
- Management Involvement
- Operations Committee Improvements
- Ownership
- Expectations for Site Organization
- Complete and Accurate Information
- Operation Under NOED
- Plant Event Investigation and Recovery Process NMC:>
28
NRC Communications
- Complete and Accurate
- Verification and Validation Process
- Regulatory Compliance Organization
- Inspection Support Process
- NRC Confidence in our Communication NMC) 29
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Overall Sum_mary______
- ... PINGP provided NRC with as complete and accurate information as possible
- ... Lack of aggressive OE investigation inhibited root cause analysis and technical conclusions
- ... Prompt action when new information raised questions with initial technical conclusions
- ... PINGP provided all relevant documents to NRC NM9 32
Broader Initiatives
- Performance Improvements
- Management changes
- Staff realignment
- Formal processes
- Clear management expectations, standards, accountabilities
- Process assessment
- Priority Issues
- Long-term Goals NM~
'.f-*. _
33
Conclusion
~Actions were not willful violations
~Corrective actions are in place
~NRC enforcement action is not warranted
~Enforcement discretion is warranted NM~
34