ML20059M834
| ML20059M834 | |
| Person / Time | |
|---|---|
| Site: | Diablo Canyon  |
| Issue date: | 08/17/1993 |
| From: | AFFILIATION NOT ASSIGNED |
| To: | |
| References | |
| OLA-2-I-MFP-028, OLA-2-I-MFP-28, NUDOCS 9311190367 | |
| Download: ML20059M834 (13) | |
Text
HUCLEAR RECUJiORY C0!AW551dN
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, M SR.DCO-91-MM-N061 WW M --
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MANAGEMENT
SUMMARY
During walkdowns of the 85' elevation of the turbine building, QA identified discrepancies in the lubricants storage area.
This is documented in.QA Assessment # 91025I.
These discrepancies on storage and handling of lubricants include unlabelled and mislabelled grease guns, potential cross contamination of greases through the use of a single pump.
This is considered a nonconformance by senior management per QAP 15.b paragraph 2.1.8.
The root cause of this event has been determined to be a lack of specific ownership of the lubricants storage area.
The immediate corrective actions were as'follows:-
The PM's as required by AP C-750 which require lubrication were either rescheduled or postponed pending.evalua+ ion of the lubricants.
Evaluation of the mixing of lubricants or the usage of the wrong lubricants were conducted and no potential adverse effects on equipment were noted.
J w
me ex-The corrective actions to prevent recurrence are:
1.
Mechanical maintenance will appoint a foreman prior to 2R4 to oversee the lubrication storage area, to include a weekly surveillance of the area to insure requirements are met.
I 2.
Mechanical maintenance will perform an additional monthly audit of the area.
l 3.
Enhance and standardize the markings on the grease-dispensing tools.
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'm NCR DCO-91-MM-N061' October =25, 1991 r
NCR DCO-91-MM-N061 STORAGE AND HANDLING OF LUBRICANT i
I.
Plant Conditions Modes and power of operation are not applicable to this condition.
II.
Description of Event A.
Event:
During walkdowns of the Turbine' Building 85'
)
elevation, QA identified several discrepancies
'in the lubricants storage area. This is documented in QA assessment # 91025I. :These discrepancies on handling and storage of-lubricants are listed below:
A.
.ALLincoln model-1035 grease'gunL(scribed 4430-4020'PG&E MM) had a brass' tag attached indicating " Exxon EPO EQ"' type grease.
Installed in the gun was a cartridge of
" Chevron Dura-Lith grease EP-2". The cartridge was virtually empty.
B.
Visual inspection of-thefone hand pump'for 35 pound grease cans wa= performed. The pick up tube for the pump contained 3.
different colors of grease mixed together.
This pick up tube can hold approximately 40 ounces of'%rease.
This-pdf) is used 4m for multiple types of greases.without clearance of.the pick-up tube.
C.
2 Hi pressure grease guns werefnot marked with' the type: of grease installed as ' required by AP D-753.
D.
Inspection of the hand-oil pump'for 55 gallons barrels determined that approximately one cup of oil remained in the pump.,This-amount is insignificant when'large quantities of oil are dispensed.
However,.when smaller quantities are needed, such as a: pint, mixing of incompatible lubricants could result.
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NCR DCO-91-MM-N061 October 25, 1991 l
E.
Grease guns are typically marked'as containing "EP-2".
There are various types of EP-2 such as Duralith, Polyurea, moly, and Ultra Duty.
The grease guns should be marked l
I with the specific type of EP-2.
F.
Obsolete revision of AP D-753 was fouild in the lubricants storage room.
l The procedure found was revision 17, the current revision is revision 18.-
B.
Inoperable Structures, Components, or Systems-i that Contributed to the Event:
l None.
C.
Dates and Approximate Times for Major Occurrences:
1.
July 12, 1991; _:_ PST:
Event and
.{
discovery date.
D.
Other Systems or Secondary Functions Affected:
None.
E.
Method of Discovery:
During walkdowns of the turbine building, 80' elevation, the QA auditors identified problems of storage and handling of lubricants in the lubricants storage roon..
j F.
Operators Actions:
None.
l l
G.
Safety System Responses:
None.
III.
Cause of the Event
{
A.
Immediate Cause:
l Violation of procedure AP D-753.
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t NCR DCO-91-MM-N061
. October 25, 1991 B.
Determination of'Cause:
1.
Human Factors:
a.
Communications:
No.
b.
Procedures:
-No.
c.
Training:
No.
d.
Human Factors:
1.
Sign on'the. door provides
)
instructions,.but personnel can pass by it without reading it on-the way to the equipment.
2.
The labeling on some' grease ~ guns is 7
'not easy (to read.
3.
The lighting ~in the. area.could be enhanced.
e.
Management System:
I Lubricants storage and handling.are-difficult to control due'to? multiple ownership of the lubricants, room.
2.
Equipment / Material:
- S * -
a.
Matc~ria' D'egradation:
No.
l b.
Design:-
No.
c.
Installation:
No.
d.
Manufacturing:
No.
L e.
Preventive Maintenance:
No.
f.
- Testing
No.
- g.. End-of-life failure:
No.
1 i
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1 e-NCR DCO-91-MM-N061 October 25, 1991 C.
Root Cause:
Lack of specific ownership of.the-lubricants storage area.
D.
Contributory Cause:
1.. Identification of lubricants is unclear and lack uniformity. ! Dispensing mechanisms are not clearly 7 identified.
2.
Lack of personnel attention to details.
IV.
Analysis of the Event
[
?
A.
Safety Analysis:
The potential for mixing incompatible lubricants involved very.small amount.
These small j
quantities'would not' result in degrading the safety functions of. plant: installed safety related equipments.
In cases where large quantities of lubricants are mixed or substituted, the expected consequence on this safety equipment would be an'. increase'in wear l
rate, with no failure.
l Therefore, the consequences of this event. willinot affect the health'and safety of the public.
B.
Reportability:
i 1.
Revie9ed under QAP-15.B*and determined tu"be n.
non-conforming'in accordance with Section 2.1.8.
I 2.
Reviewed under 10 CFR 50.72 and 10 CFR 50.73 per NUREG 1022 and determined'not to be reportable.
3.
This problem does not-require a 10 CFR 21 report.
4.
This problem does not require reporting via~an INPO Nuclear Network entry.
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NCR DCO-91-MM-N061 Octcber 25, 1991 5.
Reviewed under 10 CFR 50.9 and determined to be not reportable since this event does not have a significant implication for public health and safety.or common defense and security.
6.
Reviewed under the criteria of AP C-22 requiring the issue and approval of a JCO and determined that no JCO is required.
V.
Corrective Actions A.
Immediate Corrective Actions:
)
The PM's as required by AP C-750 which require lubrication were either rescheduled or postponed pendAng evaluation of the lubricants.
Evaluations of the mixing of lubricants or the j
usage of the wrong lubricants were conducted and no potential adverse effects on equipment'were noted.
B.
Investigative Actions:
1.
Evaluate the compatibility between " EXXON EPO EQ" and " CHEVRON DURA-LITH" grease, as described in item "A" of AR # A0236366.
In addition evaluate ituas B and D of same AR.
RESPONSIBILITY: MORGAN, D.A.
ECD: COMPLETE.
DEPARTMENT: Predittive Maintenanc6" Engineering
~^
Tracking AR:
A0236370 AE # 01 2.
Evaluate items C, E and F.of AR # A0236366.
RESPONSIBILITY: WILLIS, R.B.
ECD: COMPLETE.
DEPARTMENT: Mechanical Maintenance Tracking AR: A0236370, AE # 2 3.
Review the procedures on lubricants for adequacy.
RESPONSIBILITY:
C.
Seward DEPARTMENT:
Mechanical Maintenance Tracking AR:
A0236370, AE # 3 STATUS:
COMPLETE.
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d NCR DCO-91-MM-N061 October 25, 1991
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4.
Investigate if OPS, I&C, Mechanical Maintenance, Electrical Maintenance, and the Contractors get training on lubricants.
RESPONSIBILITY:
D.
Clifton ECD:
COMPLETE.
)
DEPARTMENT:
Training Tracking AR:
A0236370 AE # 4 5.
Evaluate the adequacy of signs in the area.
I l
RESPONSIBILITY:
D.
Stupi I
DEPARTMENT:
Mechanical Maintenance Tracking AR:
A0236370, AE # 6 STATUS:
COMPLETE.
6.
Evaluate the adequacy of lighting in the lube storage areas.
RESPONSIBILITY:
D.
Stupi ECD:
COMPLETE.
DEPARTMENT:
Mechanical Maintenance Tracking AR:
A0236370, AE # 5 l
C.
Corrective Actions to Prevent Recurrence:
i l
1.
Mechanical Maintenance will appoint one l
foreman (prior to 2R4) to oversee the j
lubricants storage area.
This responsibility will include a weekly surveillance of the area to ensure that requirements are being met.
RESPONSIBILITY:
C.
SEWARD 1
DEPARTMENT:
Mecha.._ cal Maintenance
~
- Tracking AR:
A0236370, AE # 7 -
Outage Related? No JCO Related?
No i
NRC Commitment? No CMD Commitment? No STATUS:
COMPLETE.
2.
Mechanical Maintenance will perform an I
additional monthly audit of the area.
For example, the audit may check a. sample of two or three grease guns to determine if the proper cartridges are being used in the proper guns.
RESPONSIBILITY:
C.
SEWARD DEPARTMENT:
Mechanical Maintenance Tracking AR:
A02326370, AE # 8 91-NCRWP\\91-MM-N061.PGD Page 7
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I NCR DCO-91-MM-N061 October 25, 1991 Outage Related? No JCO Related?.
No NRC Commitment? No CMD Commitment? No-STATUS:
COMPLETE.
3.
Enhance and standardize the markings ~on.the grease-dispensing tools.
RESPONSIBILITY:
C.
SEWARD ECD: COMPLETE DEPARTMENT:
Mechanical. Maintenance Tracking AR: _
A0236370) AE # 9 Outage Related? No-i JCO Related?
No NRC Commitment? No.
CMD Commitment? No i
VI.
Additional Information A.-
Failed' Components:
None.
i B.
Previous Similar Events:
NOV.50-275/87-01; 50323.87-01;LDCL 878-083, i
section 3-4.
C.
Operating Experience Review:
i 1.
NPRDS:
Not applicable.
2.
NRC Information Notices,. Bulletins, Generic Letters:
None.
3.
None.
D.
Trend Code:
Responsible-department: _ MM L (Mechanical-Maintenance) and cause' code: AH,_ personnel error; i
procedure not followed.
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n NCR DCO-91-MM-N061 October 25, 1991 E.
Corrective Action Tracking:
1.-
The tracking action request-is A0236336.
2.
Are the corrective actions outage related?
.No F.
Footnotes and Special Comments:
None.
G.
References:
1.
Initiating Action Request A0232586.
i 2.
- A0236370.
l 3.
NOV 50-275/87-01 50-323/87-01 4.
DCL 87-083 Section 3-4.
5.
Memorandum from Director Mechanical.
Maintenance to maintenance personnel dated' 8/16/91.
6.
Audit 91025I.
Subject:
DCPP lubrication program._
j 1
- ^
H.
TRG Meet'iTio Minutes:
On July 16, 1991, at 13:00 the TRG convened and considered the following:
1.
After some discussion,'it was agreed that the event description needs to be revised to include the details of the findings contained in AR / A0236336.
2..
It was agreed:that the immediate cause of.the:
event was due to the lack;of compliance to procedure AP D-753.:
3.
A Root cause.could not be' agreed upon,.and I
will be finalized at the'nextLTRGLmeeting, although it was agreed that currently the-91-NCRWP\\91-MM-N061.PGD.
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NCR DCO-91-MM-N061 October 25, 1991 responsibility for lubrication is' assigned to the area foreman.
Accessibility to lubricants is shared with-other departments.
These conditions; provide opportunity for lubrication procedure-t violations.
l 4.
Contributory causes will be decided at:the'next TRG meeting after the'results of'the investigative actions are completed.
5.
Regulatory Compliance to write the' Safety Analysis.
6.
It was decided that two investigative AE's need to be assigned. _One<to D. Morgan to evaluate items A, B'and D"of AR'A0236336, and one to R. Willis to investigate items C,.
~
E, and F of the same AR.
7.
QC to invite a representative of the-operations, electrical:and mechanical departments to attend the next.TRG meeting.-
8.
NEXT TRG TO RECONVENE ON AUGUST 6,. 1991 AT 10.00 AM.
MEETING MINUTES OP AUGUST 6.
1991 On August 6, 1991 at 10:00 AM the TRG reconvened-and considered the following:
1.
Determination of root cause which has beens agreed.to be:
Lack of ownership of the. lubricant storage a.
facility.
b.
Identification of dispensing. mechanism unclear.
c.
Lack of personnel attention.to details.
2.
Several~ corrective actions.were proposed as listed below:
Dispensing equipment needs.to be more a.
clearly identified ~and'more. manageable.
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NCR DCO-91-MM-N061 October 25, 1991 b.
There is a need to more standardization.
Guns need more ID on the barrel.
i.e. EP-2.
Some have info tags, some have brass tags.
c.
Mixing should be minimized. Grease cans should identified with the applicable procedure number.
d.
More surveillances should be provided.
3.
Contributory.causes.
a.
Apparent lack of procedural understanding b.
Lack of awareness on the controls being maintained.
4.
Two additional investigative AE's were agreed on:
a.
Evaluate the adequacy of signs in the lubricants storage areas, b.
Evaluate the adequacy of lighting in the j
lubricants storage areas.
5.
Proposed Mechanical Maintenance corrective actions:
a.
Mechanical Maintenance will appoint a foreman prior to 2R4, to oversee the lubricants storage areas.
b.
Mechanical Maintenance will perform an additional monthly audit in the lubricants storage areas.
THE TRG WILL-RECONVENE ON 09/05/91 AT.15:00 TO DISCUSS THE INVESTIGATIVE ACTIONS.
MEETING MINUTES OF SEPTEMBER 5.
1991.
On September 5, 1991, at 15:00 PDT the TRG reconvened and considered the following:
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NCR DCO-91-MM-N061
-October 25, 1991 f
1.
Review of the NCR write-up.
2.
Review of AR A0236370:.
A.
AE # 1:
1.
Item A - Change the marking.of grease guns.
2.
Item B - 3 greases)on the hand pump.
How to preclude?
3.
Item D - No.majcrisignificance on plant
~ installed: equipment.
SampleLoil on plant installed components and discard as required..
1 B.
AE # 2:
1.
Item C & E will be resolved'as part-of AE # 9.
2.
Item F will resolve AE # 7 &'8.
i C.
AE # 3:
No problem.
Will enhance the lubricants identification with additional _ marking, surveillance.. Will try_to' keep in' complionce with the procedure.:
D.
AE # 4 :
COMPLETE.-
E.
AE # 5:.
COMPLETE.
F.
AE # 7 & 8:
see item'B 2 above.
3.
No Need to reconvene.
4.
Final write up to be circulated forJsignatures and submitted for'PSRC approval..
5.
Closure-ECD:-
12/02/91.
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I.
Remarks:
None.
J.
Attachment (s):
' 1.
Initiating AR A0236336,
- 2. Tracking AR A0236370.
3.
DCL 87-083 4.
NOV 50-275/87-01 50-323/87-01'
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