ML20084J897

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AO 2-72-3:on 720426,diesel Generator 2 Tripped.Caused by Electrical Mechanic Erroneously Installing Jumpers on Unit 1 Instead of Unit 2.Shift Personnel Informed & Independent Audit Check by Third Person Added
ML20084J897
Person / Time
Site: Quad Cities  Constellation icon.png
Issue date: 05/04/1972
From: Palmer F
COMMONWEALTH EDISON CO.
To: Morris P
US ATOMIC ENERGY COMMISSION (AEC)
Shared Package
ML20084J889 List:
References
AO-2-72-3, FAP-72-94, NUDOCS 8305190044
Download: ML20084J897 (5)
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-?> Dr. Peter A. Morris, Director h0?N 7e Division of Reactor Licensing ORN [ U. S. Atomic Energy Commission S8 C3 Washington, D. C. 20545 @j g

Subject:

Quad-Cities Muclear Power Station DPR-29 and DPR Appendix A Section 6.6.A.1 and 6.6.3.2

Dear Dr. Morris:

r~ The purpose of this letter is to inform you of an operating error on Unit 2 that effec.ted the Unit 1 emergency systems, exposed a excitation system design that was not shown on the station wiring prints, and the f ailare of diesel generator No. 2. These items are reported as incident Number 2-72-3 Descrintion of Incident On April 26, 1972, the reactor water level in the Quad-Cities Nuclear Power Station reactor vessel No. 2 was to be lowered for final visual inspection of the core and shroud areas prior to vessel head installation. To prevent automatic initiation of the emergency diesel generator and the low pressure core cooling systems, jumpers were authorized by th3 operating engineer assigned to Unit 2. The shift fee-:Til and an electrical mechanic proceeded to ins tall the j umpe:.as. In error, they were installed on Unit 1 instead of Unit 2 at 7: 00 p.m. on April 26, 1972. When the water level was drained to the upper grid (11: 56 p.m. on April 26, 1972) diesel generators 2 and 1/2 started. This was not expected because of the j umpering, and the first thoughts were that the j umpers were not placed properly. Both diesel generators were loaded, and at 12: 32 a.m. on April 27, 1972, the Unit 2 diesel generator became unstable (Varmeter pegged' - Ammeter pegged) and was tripped manually. i 8305190044 720733 hDRADOCK 05000254 2293 f..- l m .-DOPY SENt nEG10N 3 f

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..'s g" es ' n.L7 O Dr. Peter Morris May 4, 1972 Investigation revealed burning and rectifier damage in the excitation section of the Unit 2 - diesel generator. The Unit 2 diesel generator was considered inoperable and taken "out of service". Tne error in jumper placement was determined and corrected by 5: 00 a.m. on April 27, 1972. Cause of the Failure and Error Regarding the failure of Diesel Generator No. 2, please refer to attached Sargent & Lundy Drawing 4E1337 The three phase rectifier circuit composed of silicon diodes CR1, CR2, CR3, CR4, CR5, and CR6 have installed for arc protection, a set of 6 selenium rectifiers reverse connected across.each of the silicon diodes. These are not shown on the wiring diagram. The selenium rectifiers shorted and caused the generator to become underexcited which pegged the varmeter > l200 MVAR -(leading) and also pegged the phase ammeter. The selenium rectifiers are installed to protect the silicon diodes. The mistake in jumper placement was human error. The fore-man on shif t was familiar with the jumper procedure and had implemented jumper placement many times. He simply stopped thinking for a minute and he was on the Unit 1 panel instead of Unit 2. -Corrective Actions A) Jumper error - When the water level on Unit 2 was lowered, the starting of Diesel Generators 2 and 1/2 indicated an error in jumper placement. The Unit 2 operating engineer was called and the shift foreman realized his mistake. The jumpers were then moved to the proper unit. The following steps were taken to guard against another jumper. placement error:

1)
  • All shif t personnel were made aware of the error and the effect it had on the Core Cooling Systems for Unit 1.

2) The incident was reviewed at the May 4, 1972 Quad-Cities Nuclear Power Station -' joint safety committee meeting. W# Y ' wss. n. p.. ,p weu

~.-..:_-. ,0 c .w.. Dr. Peter Morris May 4, 19 72 3) .esadmin trative procedure for jumpers was argumente y adding the requirement of an ndent audit check by a third person af ter the original placement and removals. 4) Discussed possibility of testing sensor circuits af ter j umper placement and removal. 5) Additional equipment and plant area labelling will be done to more clearly identify each unit. B) Excitation circuit on diesel generators - The selenium rectifiers were replaced and a study is in process with the manufacturer, Sargent and Lundy, and Commonwealth Edison Company electrical engineering department to determine the final corrective action. Very truly yours, COFFONWEALTH EDISON COIJPANY Quad-Cities Nuclear Power Station c' W F. A. Palmer Superintendent FAP/zm Enc. - Copy Dwg. 4E1337 G 9

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