ML13213A270
| ML13213A270 | |
| Person / Time | |
|---|---|
| Site: | Arkansas Nuclear  |
| Issue date: | 07/22/2013 |
| From: | Nadeau J Entergy Operations |
| To: | Office of Nuclear Reactor Regulation |
| Shared Package | |
| ML13213A272 | List: |
| References | |
| 0CAN071303, FOIA/PA-2014-0024 CR-ANO-C-2013-00888, Rev. 0 | |
| Download: ML13213A270 (190) | |
Text
Attachment 3 OCAN071303 Stator Drop Root Cause Evaluation (Non-Proprietary)
7 I
ATTACHMENT 9.11 REPORT FORMAT Page 1 of 189 Entergy Operations, Arkansas Nuclear One (ANO)
Root Cause Evaluation Report Unit I Main Turbine Genbera Sttor CR-ANO-C-2013-00888; Eve D1-2013 REPORT DAT 07-2213, Rev. 0 Position Date Evaluator J.J. Nadeau 07-22-2013 Reviewer L.A. McCarty 07-22-2013 O&P Review S.C Marrs 07-22-2013 Responsible Manager .E. es 07-22-2013 CARB Chairpersum 07-22-2013 EN-LI-1 18, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT Page 2 of 189 Problem Statement At approximately 0750 on 3/31/2013, during movement of the Unit 1 Main Turbine Generator Stator (-524 tons), the temporary lift assembly failed resulting in loss of life, loss of'off-site power to Unit 1, structural damage to the Turbine Building and physical injuries.
Event Narrative Event Entergy Operations, Inc. (Entergy) contracted with ,Siemens Energy, Inc. (Siemens) to perform Generator Modernization on Unit 1 Main Turbine- Generator Stator (stator) during Arkansas Nuclear One (ANO) 1R24 refueling outage. Si'emens subcontracted with Bigge Crane and Rigging Co. (Bigge) for crane and.rigging services to remove the original stator and install the Unit 1 refurbished stator. A description ofýhe intended lift process is included as Exhibit 1.
At the time of the event, ANO-2 was operating at 100% power and ANO-1 was in day seven of the 1R24 refueling outage. ANO-1 personnel had just completed filling the refueling canal and were in the process of checking out refueling equipment. The Bigge girders and strand jack lifting device had been raised-into place during the March 30th night shift and the lift of the stator had begun late in"that shift:
At approximately 0750 on March 31, 2013 the temporary lift assembly used to lift and transport the ANO-1 stator ffro the turbine building. failed resulting in the -524 ton stator dropping onto the ANO-i turbine deck (Elev. 386') and then rolling and falling onto the transport vehicle p'rked in the train bay (Elev. 354'). Upon the failure of the lift assembly, its structu.ral members came down onto the ANO-1 and 2 turbine deck resulting in the death of one individual, ten other injuries requiring offsite medical treatment, and multiple first aids.
The impact ofAhe stator on the ANO-1 turbine deck resulted in substantial damage to turbine buildl*g structural members and to the turbine deck floor itself in the vicinity of the impact.
The 4160 VAC switchgear Al and A2 located immediately below where the stator impacted the turbine deck were damaged, rendering offsite power sources from startup #1 and startup
- 2 transformers inoperable. The 4160 VAC supply to ANO-1 from Alternate AC Current (Black) Diesel Generator also was damaged.
EN-LI-118, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT Page 3 of 189 Falling components impacted the north wall of the train bay causing structural damage, rupturing an 8" fire main and a 2'" hose reel supply resulting in substantial fire water spray into the train bay area. The stator came to rest against the south wall of the train bay on top of the transport vehicle. Both the north and south non-structural concrete masonry unit walls of the train bay suffered substantial damage.
The shock caused by the temporary lift assembly failure and the stator falling was detected by seismic Sensor XR-8007 located on the Unit 1 Spent Fuel Pool Deck (Elev. 404') jinthe Auxiliary Building. The horizontal pseudo cumulative absolute velocity calc ulated-by-Sensor XR-8007 was 0.01242g in the north-south direction and 0.02263g in the east-west direction.
Both of these values are well below the 0.05g threshold for anticipated vibration-induced damage. The other five seismic monitors installed at the station were functioning and did not experience vibration above their recording triggers. There are two desigin basis earthquakes for ANO: 0.1g Operating Basis Earthquake (OBE) and 0.2g Safe Shutdown Earthquake (SSE). Based on the calculated results, there is no indication that vibrations exceeding 0.1g OBE occurred.
The shock from the stator contacting the turbine building, and temporary lift assembly components falling into the turbine building, caused relays; in the ANO-2 switchgear area located just adjacent to the train bay to actuate resulting in the trip of 2P-32B reactor coolant pump. This, in turn, resulted in a trip to the Unit 2'reactor, (CR-ANO-2-2013-00583). The ANO-2 post-trip response was normal wth the exception that the position indication for 2CV-0748 Feedwater Loop A Main Feedwater, Regulating Valve showed the valve to be 7.7%
open, when in fact the valve had closed as designed (CR-ANO-2-2013-00823). In response to this indication, the operators'\tripped thie main feedwater pumps and manually initiated Emergency Feedwater.
The loss of offsite power to ANO-1 resulted in the automatic start and tie into their respective safety buses of both emergency,,diesel generators. Service water pumps automatically started and restored hejaderpressure as designed. The ANO-1 operators restored decay heat removal-in a timely manner in accordance with OP-1203.028, Loss of Decay Heat Removal. The; protected red train was placed in service first, with P34A Decay Heat Removal (DHR) pump started at 0754 and DHR flow initiated at 0756. As a backup to P34A, P34B DHR pump was started at 0805 with its DHR flow path established at 0806. There are no bulk temperature readings available for the fuel transfer canal; however, during this period the E35A decay' heat outlet temperature increased from an approximate steady state temper:ature. f`770F to approximately 850F.
Response to loss of spent fuel pool cooling was performed in accordance with Abnormal Operating Procedure OP-1203.050, Unit 1 Spent Fuel Pool Emergencies. Spent Fuel Pool (SFP) cooling flow was re-established at 0813 when P40B SFP Cooling Pump was started.
Intermediate Cooling Water flow was momentarily established at approximately 0930, after an offsite power source had been connected and established for longer-term operation EN-LI-1 18, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT Page 4 of 189 approximately one hour later at 1030. From 0750 to 1043, spent fuel pool temperature rose approximately 2.8 0F from 87.0°F to a peak of 89.80 F (design temperature of the spent fuel pool is 200 0 F).
Immediate attempts were made by Operations personnel to isolate fire water spraying from the broken fire water piping into the train bay area. A field operator was dispatched to shut down the fire water pumps in the ANO-1 intake structure. Power to the electric fire pump was lost due to damage to the A-1 switchgear. The field operator did not immediately recognize a temporary electric motor-driven fire water pump was in service at thisý time supplying water to the header (CR-ANO-C-2013-01072). The temporary fire water pump was subsequently secured. Spray from the fire water piping rupture, migrated into the ANO-2 switchgear area. The fire water that had pooled on the floor in the switchgear area entered the 2A1 switchgear at the location of the 2A-113 breaker cubicle zcausinrg -an electrical fault at approximately 0923 on the 2A-1 4160V supply bus from start-up iran~sformer #3 (SU3). This fault resulted in a protective relaying lockout of SU3 which tripped all SU3 feeder and load breakers (CR-ANO-2-2013-00565). Switchgear 2A-2 was':deenergized following the SU3 lockout resulting in a loss of offsite power to 2A-2 and 2A-4. ý,The 2K-4B emergency diesel generator started as designed and supplied safetybus 2A-4. Start-up transformer #2 (SU2) feed to 2A-2 breaker 2A-211 was in pull-to-lock per OP-2107.001 Electrical System Operation, (normal configuration). Switchgear 2A-* successfully slow transferred its feed to SU2 and provided power to 2A-1 and safety bus 2A-3. Switchgear 2A-1 remained energized throughout the event. Figure 1 depicts6th-eANO-Z high voltage distribution system.
EN-LI-1 18, Attachment 9.11, Rev 18
ATTAcHMENT 9.11 REPORT FOPmAT ATTACHMENT 9A I REPORT FORMAT Page 5 of 189
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BREAKERSVtaeRqitr AT 22KV Voa~e Raulaksi1617KV RIS
- 3 SUL #2SU 16 ~ 6. M4.I6 2H24 2AM2 2H2S 2A2 M*M 2X-31 ". d dining ZR14wh., IM 2,.Iwnbn .d..ii.kbin6 Loss of SU3 90V buses 2H-1 and 2H-2 caused the loss of power to the two running Reactor Cos t(RCP) and the one running circulating water pump. Accordingly, the plant orato c ced a natural circulation cooldown using the atmospheric dump valves The loss of bus 2-A2 resulted in a loss of power to one of two instrument air compressors and the lowtransfer to SU2 resulted in the loss of the second instrument air compressor, which in combination with loss of both ANO-1 instrument air compressors, caused the instrument air header which was cross-tied between the units to depressurize, complicating the ANO-2 response.
EN-LI-118, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT Page 6 of 189 A Notification of Unusual Event (NUE) was declared at 1033, based on EAL HU-4, fire or explosion, following confirmation that the lockout of SU3 was due to an electrical fault in the switchgear at breaker 2A-1 13 with indications reported of bus damage.
The operator response to the event was effective with actions taken to maintain:the plants in a safe and stable condition despite the challenges associated with the lift assembly failure, medical response for injured personnel, and the challenges associated with degraded power condition, Safety systems performed as designed, aiding the operators in the fevent recovery. Appropriate actions were taken on both units to respond to the,,conditionýcreated by the stator drop. The station's response ensured satisfaction of Entergy~s obligation to protect public health and safety.
.S.
An assessment of the ANO-1 Operations Response to the Event is,contaidned in Exhibit 2a.
An assessment of ANO-1 Equipment Response on 3/31/2013 is contained in Exhibit 2b. An assessment of Unit 2 Operations response to the event is contained in Exhibit 3.
Scope The scope of this Root Cause Evaluation (RCE) is to'-evaluate the cause of the temporary lift assembly failure and the consequences from.'a personnel safety and equipment damage perspective. Two firms were includedi!i the ,RCE-te.am to provide their independent subject matter expertise. performe.l evidence collection and structural analysis.
Ieva ona andr¢ ealle organizational ontol associated with and programmatic controls uman peo rmance and industrial safety.,
Additional condition reports coosed-,to this RCE and how the CRs are addressed are identified in Attachment 7 - CR's losed to CR-ANO-C-2013-00888 The purpose of this RCE istoestablish corrective actions to assure that conditions that led to the temporary lift assembly failure are promptly identified and corrected and that measures necessary to.prevent recurrence are identified and implemented.
Accessr'e:strictions by the stator contractor, Siemens, and its heavy lift subcontractor, Bigge, limited the ability'-of the Root Cause Team to further assess underlying causes. Had the Root'Cause Team had full access to material, personnel and records related to the event, it appears*likelyfthat additional contributing causes may have been developed. Attachment 8 identifies-some of the topics that would have been explored if access to the information and personnel were made available. Nonetheless, the information available was more than adequate to identify why the event occurred and to identify corrective actions Entergy can take to protect personnel and equipment.
EN-LI-1 18, Attachment 9.11, Rev 18
REPORTFORM ATTACHMENT 9.11 REPORT FORMAT Page 7 of 189 Root Cause Evaluation Direct Cause koft From EN-LI-1 18, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT Page 8 of 189 Event Scenario EN-LI-1 18, Attachment 9.11, Rev 18
I ATTAcHMENT 9.11 REPORT FORMAT ATTACHMENT 9.11 REPORT FORMAT Ploe q of 189 EN-LI-118, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT EN-LI-118, Attachment 9. 11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT Page 11 of 189 U
EN-LI-1i18, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT PAnp 19 nf 1PAC EN-LI-118, Attachment 9.11, Rev 18
I REPORT FORMAT ATTACHMENT 9.11 ATTAC14MENT 9.11 REPORT FORMAT I
I EN-LI-118, Attachment 9.11, Rev 18
ATTAcHMENT9.11 REPORT FORMAT EN-LI-1 18, Attachment 9.11, Rev 18
I ATTAcHMENT 9.11 REPORT FORMAT ATTACHMENT 9.11 REPORT FORMAT Dnrum 1 A nf 1 AQ EN-LI-118,. Attachment 9.11, Rev 18
I REPORT FORMAT Analysis EN-LI-1l18, Attachment 9.11, Rev 18
ATTACHMENT 9.1.1 REPORT FORMAT Pa~qe 17.of 189 EN-LI-118, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT Paae 1,8 of 18c EN-LI-118, Attachment 9.11, Rev 18
I ATTAcHMENT 9.11 REPORT FORMAT 9.11 REPORT FORMAT p2mim 1 Q nf I AC ATTACHMENT EN-LI-118, Attachment 9.11, Rev 18
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I ATTACHMENT 9.11 REPORT FORMAT Page 23 of 189 I
I EN-LI-1.18, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT P;nA 94 nf 1PA EN-LI-1 18, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT Dona Is f I RcQ EN-LI-118,. Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT D~f' Orf I no DirectCause is defined as:
The action or condition that occurs immediately prior to the consequential event that is being investigated;may be consideredas the'trigger"'forthe event.
DC1 The direct cause of the temporary lift assembly collapse was buckling of the northwest lower column.
Root Cause is defined as:
The most basic cause(s)fora failure or a condition that, if corrected or eliminated, will preclude repetition of the event or condition..
RCI - The root cause of the temporary lift assembly collapse is that the Bigge design did not ensure the lift assembly north tower could support the loads anticipated for the lift. 'DC1 Ci- Design analysis deficiency F
I RC2- Bigge failed to perform required load testing of their modified temporary lift assembly prior to its use at ANO in accordance with OSHA regulation.
MTI E -Testing not performed as required EN-LI-118, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT Page 27 I
I Contributing Causes:
Contributing Cause is defined as:
An identified cause that ff corrected would not by itself have prevented the event. This type of cause may have facilitated the event's occurrence, increased its severity, or lengthened the time to discovery.
CCI - Siemens and Bigge inaccuratel epresented, that the hoist assembly had been used at other electric power stations to lift iponerit that exceed the anticipated weight of the unit 1 stator.
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I ATTACHMENT 9.11 REPORT FORMAT Page 28 of 189 CC2 - Siemens failed to provide adequate oversight and control of Bigge's performance CC3 - EN-MA-1 19 does not provide clear. guidance regarding independent reviews of special lift equipment I
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I CC4," Supplemental Project personnel lacked sufficient knowledge of OSHA and
.ASME NQA-l.'application to temporary lift assemblies and accepted Bigge's assertion that,l6ad testing was not required based on a combination of engineering analysis and previous use.
I EN-LI-118, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT Page 29 .of 189 Oraanizational and Proarammatic Weakness Evaluation EN-LI-118, Attachment 9.11, Rev 18
.1 ATTACHMENT 9.11 REPORT FORMAT Paqe 30 of 189 EN-LI-1 18, Attachment 9.11, Rev 18
I ATTAcHMENT 9.11 REPORT FORMAT ATTACHMENT 9.11 REPORT FORMAT nnx'a1 -f 1 QC Safety Culture Evaluation (provide: summary):
EN-LI-118, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT D,"J '1'3 ^"f 4 EN-LI-1i18, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT Page 33 of 189 Generic Implications: Extent of Condition and Extent of Cause Extent of ProblemlCondition:
EN-LI-1 18, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT Page 34 of 189 Extent of Cause:
EN-LI-1 18, Attachment 9.11, Rev 18
I ATTAcHMENT 9.11 REPORT FORMAT Dý ar,^f 1o EN-LI-118, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT.
I Page 36 of 189 EN-LI-118, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT Paae 37 of 189 V
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ATTACHMENT 9.11 REPORT FORMAT Page 38 of 189 Previous Occurrence Evaluation Policies and Proceduresi:*,*
EN-LI-i18, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT Paae 39 of 18ý OE Conclusions Safety Significan*-e Evaluation EN-LI-1i18, Attachment 9.11, Rev 18
REPORTFOR ATTACHMENT 9.11 REPORT FORMAT I-ýý
ATTACHMENT 9.11 REPORT FORMAT 0--- Al -
,4on EN-LI-1 18, Attachment 9.11, Rev 18
I REPORT FORMAT ATTACHMENT 9.11 ATTACHMENT 9.11 REPORT FORMAT EN-LI-118, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT Page 43 of 189 Corrective Action Plan All root and contributing causes, and generic implications must have corrective actions or a documented basis why no action is recommended.
Identified Cause Corrective Actions; :Responsible 'Due:Date Dept.: .. .... _
Immediate Actions Interim Actions EN-LI-11 8, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT EOTFRA FORMAT ATAHET91 EN-LI-1 18, Attachment 9.11, Rev 18
I REPORT FORMAT "-
Corrective Actions iort & Lona Term Actions I
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I EN-LI-1 18, Attachment 9.11, Rev 18
ATTAcHMENT 9.11 REPORT FORMAT Paae 46 of 189 Identified. Cause: Corrective Actions Responsible 'Due Date I Dept.,
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I ATTACHMENT 9.1l REPORT FORMAT *.
Page 47 of 189 Identified Cause:
EN-LI-1 18, Attachment 9.11, Rev 18
I ATTAcHMENT 9.11 REPORT FORMAT Paae 48 of 189 ... ::
a 48 of 189 Identified Cause Corrective Actions Responsible .Due Date
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EN-LI-118, Attachment 9.11, Rev 18
I ATTAcHMENT9.li REPORT FORMAT ATTACHMENT 9.11 REPORT FORMAT EN-LI-1 18,.Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT Page 50 of 189 Effectiveness Review Plan This section should contain an Effectiveness Review strategy that includes the following:
Method - Describe the method that will be used to verify that the actions taken had the desired outcome.
Attributes - Describe the process attributes to be monitored or evaluated.
Success - Establish the acceptance criteria for the attributes to be monitored or evaluated.
Timeliness - Define the optimum time to perform the effectiveness review.
- 1. E-tectlveness review actions are requirea Tor all G;P-IS.
CAPR:A DESCRIPTION "..,
Method:
Attributes:
Success:
Timeliness:
Owner Group.*', ,rojcts Due Date:
CAPR?2.
DESCRIPTION Method:
EN-LI-1 18, Attachment 9.11, Rev 18
I ATTACHMENT 9.11 REPORT FORMAT REPORT FORMAT Page 51 of9.11 ATTACHMENT 189 Attributes:
Success:
Timeliness:
Owner Group: Projects
- Repeat the above for each CAPR, as required.
- Similar MAST criteria may also be shown for other important corrective actions.
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EN-LI-118, Attachment 9.11, Rev 18
ATTACHMENT 9.11 REPORT FORMAT Page 52 of 189 TREND DATA (coordinate entry in the PCRS Trend Table of this CR):
Cause Codes:
Human Performance Causal Factor(s) (List all),
O&P Causal Factor(s) (List all):
Equipment Causal Factors (List all):
EFE Codes:
INPO ER PO&C Codes'.
Failure Mode Codes:
Safety Culture Evaluation Codes:
NSC-NRC Codes (List all):
NSC-INPO Codes (List all):
Other Trends Codes Operator Fundamental Keywords (List all): None References Documents Reviewed Refer to Documents Listed inCobmparative Timeline.
Personnel Contacted First Last Name Company
. Position, Title Responsibilities Location Interview Shift Name During Date I I . II.I. Event II m------
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I ATTACHMENT 9.11 REPORT FORMAT Page 58 of 189 Team Members Exhibits Exhibit I Intended Lift Process Exhibit 2a Assessment of ANO-l Operator Response on 3/31/2013 Exhibit 2b Assessment of ANO-1 Equipment Response on 3131/2013 Exhibit 3 ANO Unit 2*mpacts-,
Exhibit 4 Code Requirements Exhibit 5 Bigge .Gantry Crane Tower System Failure Contingency Plan Analysis Methods Used. FaultTree' Events,,, nnd Causal Factors Chart a tructural Evaluation Status Report b. Failure Modes Analysis Comparative Timeline Attachment,5 Evaluation for Organizational and Programmatic Issues Safety Culture CRs Closed to CR-ANO-C-2013-00888 Acknowledgement of limitations Operating Experience Review EN-LI-118, Attachment 9.11, Rev 18
EXHIBIT 1-INTENDED LIFT PROCESS Page 59 of 189 The swap of the Unit 1 stator was planned to follow the following basic flow.
A portable gantry system is assembled between the Unit 1 stator and the train bay. Stations are placed at the south end of the gantry system.
A tower is assembled at the north end of the gantry system in the train bay.
Te it I stator is lifted. The pocr requires that the load is mponitoed to ensure there is not an o d due to binding or unexpected wh The load is level to within specifcations, iThe load is then transported to the train bay and rotated to lower into the bay.
The s rotated to align with the train bay.
EXHIBIT 1 - INTENDED LIFT PROCESS Page 60 of 189 The stator is lowered on to the Goldhofer.
Scaffolding is built to gain access to remove the rigging. Once the rigging is removed, the stator is then removed from the train bay. The modernized stator is brought into the train bay and the process is reversed to return the modernized stator to the stator pedestal.
EN-LI-118, Attachment 9.11, Rev 18
Exhibit 3131/2013 Summary Assessment of Crew Performance The Unit 1 operating crew effectively responded to the event on 3/31/13 with the following key results:
" Decay Hear Removal (DHR) function was restored within five minutes
" Spent Fuel Pool (SFP) cooling function was restore in a timely manner with less than 3 0 F rise in SFP temperature
" Emergency medical response was initiated in a timely manner and effectively coordinated Crew response was aided by the presence of additional licensed personnel* who were in the control room as planned for support of the refueling outage. Theseoperators assisted with the medical emergency procedure, ERO, , interface, station log maintenance, etc.
The Shift Manager remained in his oversight role and exercised his responsibility throughout the event. He appropriately used the' team, including ERO and outage support personnel, to respond to the event. The CRS maintained command and control and used transient briefs throughout the day to maintain priorities and alignment.
Key Actions and Related Procedures
- 1. Restoration of Decay Heat Removal pert-OP-1203.028, Loss of Decay Heat Removal Decay Heat Removal function was restored in accordance with (lAW) Section 6.0 of OP-1203.028, Decay Heat Pump Trip. The protected red train was placed in service first with P34A*bDHRk pump started at 07:53:51 and DHR flow initiated at 07:55:49.
As a backup to P34A, P346 DHR pump was started at 08:05:17 with DHR flow established atO08:066:110.
The- order for containment closure was initiated by the Shift Manager and appropriately' resbinded after DHR was restored.
" DHR was established in a timely, controlled manner lAW the Abnormal Operating Procedure with no anomalies noted.
- 2. Response for Loss of Offsite Power Source to 4160V Electrical Buses per EOP-1202.007, DegradedPower.
Proper automatic system response was verified per EOP-1202.007. This included verifying EDG operation per Repetitive Task 21, verifying cooling flow to the EDGs, verifying auto-start of Service Water pumps, and aligning feeder breakers to non-vital switchgear in Pull-to-Lock status.
61
Exhibit 2a - Assessment of ANO-1 Operator Response on 3/31/2013 At the time of the event, electrical alignments were in progress to support planned activities for the Green Train maintenance window of 1R24. These resulted in the following initial conditions:
- a. A2 4160 V bus was de-energized
- b. A3 and A4 4160 V buses were initially cross-tied
- c. B5 and B6 480 V buses were cross-tied
- d. D06 Green Train battery had been disconnected from D021bus
- e. D04B battery charger was supplied from Swing MCC B56 to provide power to Green Train DC bus D02 during the Green Train outage. B56 was aligned to B5 at the time of the event.
Following the event, actions were taken to restore normal electrical alignment.
These included re-connecting the green train, battery and restoring normal alignment for B5 and B6 vital 480V buses. The cross4t1e'between A3 and A4 switchgear automatically separated on an undervoltage signal.
Response to loss of offsite power was performed in a timely, controlled manner lAW the applicable procedures with noanomalies noted in operator performance.
- 3. Response to loss of spent fuel pool cooling) per AOP-1203.050, Loss of Spent Fuel Pool Cooling Response to loss of SFP cooling was performed lAW AOP-1 203.050. Spent fuel pool cooling flow was re-established at 0813 when P40B SFP Cooling Pump was started. Intermediate Cooling Water Flow was momentarily established at approximately 0930.after an offsite power source had been connected and established for longer term"operation approximately one hour later at 1030. From 0749 to 1043, Spent Fuel Pool temperature rose approximately 2.8 0 F from 87.0°F to a peak of 89.8*F.
Power to P33C ICW pump was restored via a planned Temporary Modification that-rovided power from an offsite source unrelated to the Al and A2 4160V Switchgear damaged in the event.
The delay between 0930 and 1030 in restoring ICW flow was the result of variation in ICW surge tank levels observed when P33C was initially started. This was attributed to repositioning of ICW Suction and Discharge cross-connect valves on loss of Instrument Air. The crew chose to maintain the ICW pump idle until the two ICW loops could be cross-connected at both the suction and discharge headers for the ICW pumps. This configuration was established within approximately one hour and long term SFP cooling capability was then restored.
The planned temporary alteration providing diverse power to the ICW pumps proved very useful in restoring Spent Fuel Pool cooling. SFP cooling was 62
I Exhibit 2a - Assessment of ANO-1 Operator Response on 3/3112013 established in a timely and controlled manner with less than 30F rise in SFP temperature.
- 4. Fire Water Leak When the fire water leak was reported to the control room, the Shift Manager and CRS appropriately decided to depressurize the fire water system. O'jperators were dispatched to the Intake Structure to secure the fire water pumpslocally.
While at the intake the operator successfully secured the diesel driven fire water pump but later recognize the temporary motor driven fire water pump beig supplied power from the London line was in operation. The temporayfire ater pump was secured at approximately 0820 hours0.00949 days <br />0.228 hours <br />0.00136 weeks <br />3.1201e-4 months <br /> (CR-ANO-C-2013-01072 was initiated to assess the timeliness of securing the temporary ,fire pump). The action to secure fire water was appropriate for conditions and compensatory actions were promptly initiated to stage portable fire. water pumps and obtain assistance from the London Fire department. Technical R'quirements Manual (TRM) requirements for the fire suppression system were appropriately considered.
During the event the "At-the-Controls" (ATC) operator observed "Dirty Waste Panel Trouble" alarm K09-F5 had alarmed and that the Auxiliary Building Sump level was high. The Waste Control Operator (WC'0) was dispatched to elevation 317' and water was observed to be accumulatinglin the general area. The WCO inspected the Decay Vaults and observed no accumulation of water at that time.
The WCO had previously verified that the, DH vault doors were dog closed and the DH vault drain isolation valves ABS-13 and ABS-14 were closed. Water level in the general area'on elevation 317' reached approximately 1.5" and stopped rising as the fire *water pumps had been stopped. Later a comparable water level was observed. to have accumulated in the 'B' DHR vault. Components in the DHR vault were, not challenged by the accumulation of water; however, this condition did indicate probable leakage through vault isolation valve ABS-13.
Water level, in the 'B, DHR vault was not sufficient to actuate the level switch associated with K09-D4, Train B Decay Heat Room Flood, which has an actuation setpoint of approximately 1.6 inches (CR-ANO-1-2013-00824 and CR-S:-ANO-C-201.3-01129).
- 5. Response to Loss of Instrument Air per AOP-1 203.024, Loss of InstrumentAir
. The majority of actions dictated by the Loss of Instrument Air AOP were not applicable for the conditions present at the time of this event. Consequences of the loss of Instrument air included:
- a. DHR Cooler Bypass Valves CV-1432 and CV-1433 failed closed
- b. Pneumatic DHR pump suction temperature indications failed low
- c. ICW pump cross-connect valves failed closed.
63
Exhibit 2ai- 1 3131/2013 Failure of the DHR cooler bypass valves was anticipated by the Control Room staff. The 'A' DHR train was aligned with the cooler bypass valve fully closed prior to the loss of instrument.
For ICW cooling, the 'C' ICW pump had been selected for operation.
Consequently, a flow path for the Nuclear ICW loop existed when Instrument Air was lost.
- 6. Emergency Classification per OP-1903.010, Emergency Action Level Classification Criteria for Emergency Action Level classification were reviewed, by the Shift Manager and peer checked by other Senior Reactor Operators present in the Control Room. No applicable criteria were identified.
- 7. Emergency Response/Notifications per OP-1 903.011, Emergency Response/Notifications K' The Shift Manager elected to staff the ANO Emergency Response Organization based on the complexity of the event. ERO" staffing was initiated via voice message lAW OP-1903.011.
A courtesy call to the Arkansas Department, of Health and NRC Operations Center was performed lAW OP-1903.011 for this event of Potential Public Interest.
- 8. Response to Injuries per OP-1i903.023 PersonnelEmergency Emergency medical- team was dispatched and ambulances were promptly requested lAW the instructions of form OP-1903.023B.
- 9. Response to Loss of Control Room Phones and Plant Computer Network Normal phone service was lost momentarily during the event. Using instructions provided witeh herStation Blackout procedure tab, analog phones were placed in service and verified functional within a matter of minutes.
An extra. Reactor Operator was assigned responsibility for the station log. When computer network problems affected access to the station log application, a paper log was maintained and later transferred to the electronic log.
64
I Exhibit 2b - Assessment of ANO-1 EauiDment Resnonse on 3131/2013 Summary Assessment of Plant Equipment Response The event had the following significant, direct impacts to plant equipment:
- 4160 VAC Switchgear Al and A2 were damaged, rendering offsite power sources from Startup #1 and Startup #2 Transformers inoperable
- 4160 VAC supply from AACDG via 2A9 Switchgear was damaged and rendered inoperable
- Firewater lines in the train bay were severed, requiring that fire water purhps be secured
- Instrument Air header pressure was lost when shared source from Unit 2 degraded due to the loss of 2A2.
- Key safety systems functioned as designed with the, following highlights:
- Both Emergency Diesel Generators automatically started and tied to their respective bus
" Service Water pumps automatically.,started and restored header pressure as designed .
Both trains of DHR responded as designed when placed back in service Equipment necessary to support Spqnt Fuel Pool cooling operated as necessary to restore SFP cooling with lessthan 30 F rise in SFP temperature.
Sealing pressure to the nozzle dams on the lower Steam Generator manways slowly lowered after power was lost, to associated support equipment. Compensatory actions were taken to provide an alternate means of pressurizing the seals. (CR-ANO-1-2013-00830).
Water ingress was :noted in"the vault for the B train of DHR equipment indicating probable leakage through the associated drain isolation valve (CR-ANO-1-2013-00825).
Water did not leak, into the vault for the A train of DHR.
Sysstem Level, Review 1.: Electrical System At the time of the event, electrical alignments were in progress to support planned activities for the Green Train maintenance window of 1R24. These resulted in the following initial conditions:
- A2 4160 V bus was de-energized
- A3 and A4 4160 V buses were initially cross-tied 65
Exhibit 2b - Assessment of ANO-1 Equipment Response on 3131/2013 m n I
" B5 and B6 480 V buses were cross-tied
" D06 Green Train battery had been disconnected from D02 bus
" D04B battery charger was supplied from Swing MCC B56 to provide power to Green Train DC bus D02 during the green train outage. B56 was aligned to B5 at the time of the event.
Review of the accident video and comparison of timing between Unit 1 Loss of Power and Unit 2 Reactor Trip suggests that Al Bus locked out early in the accideht sequence, perhaps when the stator first impacted the turbine deck.
After Al locked out, EDG #1 properly started and achieved rated voltage and frequency within 15 seconds. On the other hand, starting of EDG #2 was delayed as no DC power was present for associated relaying and control components. This was expected for the configuration with D06 battery disconnected for replacement.Once*power was restored to DC bus D02 via charger D04B, EDG #2 started and provided power to associated components.
- 2. Service Water Service Water components functioned as designed with no anomalies noted.
- 3. Decay Heat System DHR components functioned as designed with one minor anomaly noted. A few hours after initiation of the event, the Low Pressure Injection flow indicator for Loop A DHR/LPI failed low: (CR-ANO-1-2013-00830)
- 4. Steam Generator Nozzle Dams As documented in CR-ANO-1-2013-00830, sealing pressure for the Steam Generator nozzle dams slowly lowered after loss of power to support equipment.
Compensatory actions were taken to provide an alternate means of maintaining sealing gas pressure.
- 5. Spent Fuel Pool Cooling and Intermediate Cooling Water Spent Fuel Cooling Pumps, which are powered from vital buses 85 or B6, functioned as designed. Intermediate Cooling Water was restored through use of a planned Temporary Modification which provided power from an unaffected off-site source.
P33C was selected as the pump to receive temporary power due to its association with the Nuclear ICW loop.
During restoration of Intermediate Cooling Water, variation in ICW surge tank levels was noted when P33C 1CW pump was initially started in Single Loop, Single Pump 66
Exhibit 2b - Assessment of ANO-1 Equipment Response on 3/31/2013 mode of operation (cross-connect valves closed due to loss of Instrument Air). This indicated possible leak by associated cross-connect valves (CR-ANO-1-2013-00912). Once Instrument Air pressure was restored and ICW loops were cross-tied, stable surge tank level was observed.
- 6. Auxiliary Building Leakage into the Auxiliary Building was noted as documented in CR-AN 1 00824. No adverse equipment consequences were noted as result Qfthi ak .
Additionally, leakage into the 'B' Decay Heat Vault was noted as doumt CR-ANO-1-2013-00825, indicating probable leakage past vault drain isa n valve ABS-1 3.
- 7. Components Supported by Instrument Air When Instrument Air pressure was lost, compon rJesponded as expected.
Noteworthy impacts included:
- a. DHR Cooler Bypass valves failed dosed,,r
- b. ICW Pump Cross-Tie Valves Failed Closed
- c. Pneumatic DHR Pump Suction Te tu icators failed low.
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This assessment was performed to evaluate the ANO-2 response to the U1 stator drop event on 3/31/13. This event was a challenge to the operators and was successfully navigated without major issues identified in the operations team performance. A summary of the emergency/abnormal procedures implemented during the event and recovery include:
- Standard Post Trip Actions Reactor Trip Recovery Loss of Instrument Air Personnel Emergency
- Fire Water Main Rupture response
- Spent Fuel Pool Emergencies
" Fire and Explosion
" Natural Circulation The following provides a lis~t of the rmajor, challenges and activities that were present throughout the day. ,tThisiassessment starts at the time of the U2 plant trip and extends through the end ofshift brief,(1830). Each of the following items are addressed in further detail in CR-ANO-2-2013-00903 CA-1.
- U2 reactor trip due to 'B' RCP breaker tripping. on motor differential relay (vibration) as a result of the stator impact to the U2 turbine
-building struc~ture.'
" Firewater turbine building main ruptured in the train bay
- Personnel Emergency procedure entered
,\ 'Standard post trip actions (SPTA) implemented and compensatory actions taken for 'A' Main Feedwater Regulating Valve (MFRV) Failure.
Running Main Feedwater Pump (MFP) tripped and Emergency Feedwater Actuation System (EFAS) actuated.
- Response to fire water spraying on plant equipment
- Control Room (CR) isolation due to rad monitor (RI-8001) actuation -
manually placed CR on emergency recirculation
3.0.3 entry) to support placing Auxiliary Feedwater (AFW) Pump in service 71
I Exhibit 3 - ANU unit z impacts
" Reset EFAS and restored 2P-7B to standby. Remained in T.S. 3.7.1.2 for throttling EFW injection motor operated valves (MOVs) using AFW
" SU#3 Lock out due to 2A1 13 (SU#3 feed to 2A1) as a result of phase to phase fault in the feed to the 2A1 bus o 2A2 de-energized and 2A4 powered from the #2 EDG. 2A1 and 2A3 slow transfer to SU#2.
o 2H1 and 2H2 de-energized. RCPs and Circulating Water Pump secured o AFW Pump tripped on SU#2 load shed o Loss of Spent Fuel Pool (SFP) cooling due to2P,40B tBVi*
o Re-entered SPTAs o Entered fire and explosion AOP o Entered Natural Circulation AOP o Entered Loss of Instrument Air AOP
" Letdown isolated, Normal Pressutizer Spray not available, Steam Dump Bypass Control System "(SDBCS) unhavailable, Running CCP tripped, RCS level rising -;Pressurizer Heaters energized and RCS heated up
" Re-started instrument air compressor (header pressure would only maintain 45 psi)
" ControlRoomý.v t W ,
phones unavailable
" Significant water'hammer on east turbine deck due to low instrument air pressure and valves cycling
" ;Momentary 4.osis of Safety Parameter Display System (SPDS) and Plant!Computer Display in CR
- . Cross tied non-vital buses 2B1 and 2B2 to allow start of the 2nd
...instrument air compressor header pressure raised to 90 psi
' Started 2P-40A SFP cooling pump
. Declared Notification of Unusual Event (NUE) (HU-4) based on minor explosion damaging plant equipment. Visible damage to back of 2A1 13 observed.
The operator response to the event was effective with actions taken to maintain the plants in a safe and stable condition despite the challenges associate with the lift assembly failure, medical response for injured personnel and the challenges associated with degraded power condition. All safety systems performed as designed aiding the operators in the event recovery.
72
Exhibit 4 - Code Requirements Material Handling Program Applicable Codes per EN-MA-119 73
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Material Handling Program Applicable Codes per EN-MA-119 75
I Exhibit 5 - Bigge Gantry Crane Tower System Failure Contingency Plan 76
I Exhibit 5- Bigge Gantry Crane Tower System Failure Contingency Plan 77
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I Anacr-ment.5o - i-atiure imaes Anaiysis ATTACHMENT 9.1 FAIL'URE MODE ANALYSIS WORKSHEET Problem Statement: On March 31, 2013, the temporary lift assembly collapsed while moving the generator stator to the train bay.
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- rajiure ivioues ,tliaiysis 97
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ATTACHMENT 9.5 EVALUATION FOR ORGANIZATION & PROGRAMMATIC ISSUES Sheet I of 13 General Guidance It is not the intent of this activity to perform a "global" (i.e., site- or system-wide) search for O&P issues (LOWs). The scope of this activity should be limited to the event bleing investigated. If this evaluation is being performed for an Apparent Cause Evaluation, then substitute the term "root" with "apparent" and "RCE" with "ACE".
The questions below are intended to guide an evaluation for "local" O&Plissues (LOWs)
- that is, those O&P issues (LOWs) which influenced the outcome of the event under investigation.They represent the failure modes of the involved Organizations and implementing Programs (i.e., work processes).
The identified O&P factors shall be either causes or new adverse conditions requiring a condition report.
" The organization is not usually aware of their potential for influencing an event.
" They are typically EXTERNAL to the observed behaviors.
Since root cause investigation is a discoveryiprocess"(a strongly knowledge-based activity, i.e., "you don't know what you don't know), this step serves as a valuable "tool" for the Evaluator (or team), to be used during the development of the causes.
This evaluation should typically be performed as part of the "Analyze" portion of the process.
For this process to be most effective, it is important that all the organizations and programs (work processes) which-,interacted during the event are known.
The Organizational aindProgramm tic qualified individual should provide oversight and coaching as necessarý during- the process.
Process The root cus-e evaluator (or team) performs each of the following steps:
- 1. ,:Screen each of the five failure mode areas to determine if the applicable causal factors maybe related to the event. Based on the results of the determination, use
.:,the O&P questions below to identify whether any causal factor indicates the presence of organizational or programmatic weaknesses.
- 2. Initiate documentation for any identified O&P issues (LOWs) that do not appear to have a "cause & effect" relationship to the investigated event - initiate a new CR.
- 3. Document the results of this evaluation (including a brief summary of supporting facts) for each of the failure modes that apply in the Organizational and Programmatic Weakness Evaluation section.
132
I Attachment 5 - Organizational and Programmatic Analysis (O&P)
- a. For any O&P causal factors identified as contributing to the event discuss how this factor is related to the appropriate cause.
- b. Discuss any identified O&P issues (LOWs) that do not appear to have a "cause & effect" relationship to the investigated event. Document the new CR initiated.
- c. Ensure failure modes that apply are evaluated and documented in this.
section.
133
Attachment 5 - Organizational and Programmatic Analysis (O&P)
ATTACHMENT 9.5 EVALUATION FOR ORGANIZATION & PROGRAMMATIC ISSUES Sheet 2 of 13 Becilnninci of Form Attach this Worksheet to the Disposition CA in PCRS if not incorporated in the RCE.
The questions are provided to promote consideration of like symptoms, not to define a specific failure mode. O&P causal factors are symptoms of the more basic causes of the event and are typically an action or condition that shaped the outcome of the..
situation.
For each causal factor block checked YES:
- 1. Ensure it is appropriately represented in the WHY Staircase as a causle or contributor.
- 2. In the BARRIER ANALYSIS, tie the O&P causal factors as appropriate to Barriers that failed, were weak, missing, or ineffective 1 ,
- 3. Summarize in the O&P section of the report how the identified Organizational &
Programmatic weaknesses caused or contributeto the event and identify the Barrier which should have prevented it.
134
Attachment 5 - Organizational and Programmatic Analysis (Q&P)
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ATTACHMENT 9.5 EVALUATION FOR ORGANIZATION & PROGRAMMATIC ISSUES Sheet 4 of 13 137
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ATTACHMENT ).5 EVALUATION FOR ORGANIZATION & PROGRAMMATIC.ISSUES Sheet 7 of 13 141
- Organizational and Programmatic Analysis (O&P) 7 1/2 142
Attachment 5 - Organizational and Programmatic Analysis (O&P)
ATTACHMENT 9.5 EVALUATION FOR ORGANIZATION & PROGRAMMATIC ISSUES Sheet 8 of 13 143
Attachment 5 onal and Programmatic Analysis (O&P)
ATTAC HM ENT 9.5 EVALUATION FOR ORGANIZATION & PROGRAMMATIC ISSUES Sheet 9 of 13 144
Attachment 5 - Organizational and Programmatic Analysis (O&P)
ATTACHMENT 9.5 EVALUATION FOR ORGANIZATION & PROGRAMMATIC ISSUES Sheet 10 of 13
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ATTACHMENT I .6 SAFEfY CULTURE EVALUATION Sheet 9 of 10 155
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- _I ATTACHMENT 9. 5 *SAFETYiCULTURE EVALUATION Sheet 10 of 10
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Attachment 7 - CRs Closed to CR-ANO-C-2013-C CRs Closed to this RCE.
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