ML20099L227

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Applicant Exhibit A-171A,consisting of 900320 Event Re Loss of Offsite Power Leads to Site Area Emergency
ML20099L227
Person / Time
Site: Vogtle  Southern Nuclear icon.png
Issue date: 09/06/1995
From:
GEORGIA POWER CO.
To:
References
OLA-3-A-171A, NUDOCS 9512200180
Download: ML20099L227 (16)
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Text

{{#Wiki_filter:.-~ - - - - ,[, I <((. .1 h '.:Q,,p.f5't;,[' 2- ~ rc examrr n. 1-A - y.. g B EX. c.1 '. n. ' t1 (,, ' . -.. ~ .,.<..u...- LOSS OF OFFSI,TE. POWER..LE 7. e. ' g5 Q.i2(}' '+ ,,.. g. r j. g EVENT DATE: 3-20-9 OEFICE '0F Ygw.9 .k A88 TRACT 00CKEJWG. g Q,f.<,<$~ f.5,&f. . 4. I.G.e an. a.., 10b%.powe *' oproMs .s umaF) BSf//di'7Js1 'fM %@. 1990,9. Unit.Q'r. wa ea Unit'2.? f On March 20, x was operating at securityf, esc'@k ~' WTdMeF m acred 7arej $J. k e % g.- truck and t driver's duties ;were to, -ma <com m

sorts Eap welding machiney staged aro,un,d the rGthe'ZDu ;ar.1 Jonmm.frii p.

l!I,Md. ! gg -="....t checke'# a welding machij,e]n theg: f.;,JkM. MM'.$hN'A m,.,,- - n o.rf A-1 ___.;fPf' ox__, n a - t ,a proccc M ackingJ gn ' he . Efe k lai3Eg* hse'N.fh, s ud= insulator for the..eserve*fuI ~~ Rcn.i s; g

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' he orme r.'i'.p.:" 0 8 2 0 CST. ' 'l. 8,ot,hiR,,Ag$ h an,s,6T'pJi1Jd'. and 1ine i.fel,1l.;t) ~Il j g insulaeor tripped at Side'and Low Side breakers.t: ~ l e s, ~og,s3te'a C^' m 57tw 30"fi'*fnTT6[' power condition (LOSP).~-s'Boyh'.! je2W uurg)).; EeraEr'ii i r i 7 (DG '.s ) s tarted, but ' the 'Urd t3, p run cau 'ing a }o_p' (jfggisJg, %gN.wgvg Rp((odG,., #fs.k second r e i A'5 Mp Trea.6mer a s E Fa c edan((T136gM Tb7 J ~5 reactor core.- NG ESA H3consc5ee site Emergenci Plan wasl.i.rnple~m'en-fit.eu.ta RWB58 SThd1HR'# 1.- degrees F before the DG was.'e'mdf ___ !I r estored. At 0915JST, the S' In Et d ici .&3' ~~

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Docht No. 50-424/425-OLA.S FXHIBITNO., N II-(7/ A $ N.$ Of 41@%

i ' In the mitter of Georola Power Co. et al Voctie Units 14 2 Z C/ 9h #Flk" M f'N' O St ff Q Applicant D intervenor 0 0ther "'*t MU! ' 2 09 Identified 5lT Rec.iv.d O Rejected Rep e $D I .. 4/ . ' ' * ~ ~ " ' i D* A4m -4C witness tu,M, 92 PRWECT 057719 r

e. A. REQUIREMENT FOR REPORT This event is reportable por a) 10 CFR50.73 (a)(2)(v11)(B), because a single event led to a system becoming inoperable which is designed to remove residual heat, b) 10 CFR50.73 (a)(2)(11), because an event resulted in the condition of the

plant, including its principal safety barriers, being seriously degraded, c) 10 CFR50.73 (a)(2)(1v), because an unplanned Engineered Safety Feature (ESP) actuation occurred when the ESF Actuation System Sequencer started.

d) Technical Specification 4.8.1.1.3, because a diesel generator failure occurred. . g.

8. UNIT STATUS AT. TIME OF EVENT 7

8.1 Power Level /.M. ode 7..g.-;... Unit 1 was i'n Mode 6 (Ref ueling)at 0% rated thermal power. The reactor was shutdo'wn 'on. 2-23-90 for a 45 day scheduled re-fueling outage. The reactor core reload, had been completed, the initial ~ paso to tension ths Ir'eactior. vessel head studs was complete, and l the outage teamwaA (saitiing permission f rom the control room ~ to i begin the final

  • tensioning.9. Reactor Coolant System (RCS) level being maintain *edl'Et 'niid-lhop' (187 '-11") with Train A Residual was temperatDre was Ts$um' ' in' isrvi,ce for decay heat Heat Removal'(RHR) p ~

removal. RCS ing' ma1'nEa1 Aed at 'approximately 90 degrees F with indication.Effrom' tso"conhected incore thermocouples. The So ayDH 'at 79% 1 /91 (app ~rox.on1.. Water'S'o'ucca was the Re Water Storage Emergency Tank (RWST).7 580,000 gallons) with boron concen'tM1Kn' of."2i57.' ppm. The Emergency Boretion Flow a Path was f rom' ths"RWST th' rough, Train A Centrifugal Charging Pump (CCP) and the. alt"einate"chardng flow path via valve 1HV-8147. Both Trains A'and 8 Safety Injection (SI) breakers were capable of being rackedl in and the p' umps operated in the hot leg i injection mode if ne,eded.t .e l ,s l . nz-3 a.*- O.2 Inoperable Equi;p. men t/Ab>n o rm.,.al System Alignment - r:M.uv ~ -:(. y. .. a,,.e ': ,. :i. Due t o t he r e f u el 1 rig,"..,.... outage.ma15tenance activities in

progress, abnormal eonfiguEa't'1T6u' t'#of.'s'ervice and several systems equipme'nti.: Eas some were in nii@ 6?M h
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i .T , r.; .g. - 92 PRCMECT 057720 .f. ,, --.... -, y j

.. ~ - t i The Train 8 Diesel Generator (DG1A) was out of service for a required 36 month maintenance inspection. The Train G Reserve Auxiliary Transformer (RAT 18) had been removed from service for en oil change. 18A03, the Train B Class 1E 4160 Volt switchgear, was being powered from the Train A RAT.(1A) through its alternate supply breaker. All Non-1E switchgear was being powered from the Unit Aux 111gry Transformer (UAT). Procedure 13417-1, " Main and Unit Auxiliary Transformer Dackfeed to the 13.8kV and 4160V Non-1E Busses' was used to establish power to Non-1E Busses i 1NA01, INA04, ar.d 1NA05. The Train 8 CCP was removed from service for various corrective 4 maintenance work orders (MHO's). The Chemical and Volume Control System (CVCS) letdown flowpath had been out of service for l various maintenance activities and was being aligned for return j to service. l Au- - %, There a;re tww ACO v;'.... sp;r u...J. 6vos...n ;nt. Tha Accumulator

  1. 4 Isolation Valve (1HV-880 Normal E

(1-12 08-U 6-03 6 )'/gD) "and jpg CVCg,,d'"9 were "81sassemble for C ha rging Check Valve repair. All Steam Generator (S/G) Nozzle Dams had been removed, i but only S/G's

  1. 1 and #4 had their primary manways secured.

l Maintenance personnel were in the process of restoring the I primary manways on S/G's #2 and #3. It was necessary to maintain l the RCS level at mid-loop for the valve repairs and the S/G manway restorations. In addition, the pressurizer manway was removed to provide a RCS vent path. I (- t C. DESCRIPTION OF EVENT On March 20, 1990, at approximately 0817 CST, a truck driver and security escort entered the protected area driving a fuel truck. l The driver's duties were to refuel air compressors and welding machines staged around the site for the outage on Un,1t 1. He had had these duties for the past three weeks. A;'tHTs Tehicle was not a " designated vehicle", as defined by plant procedure, it does not remain in the protected area, and a security escort was provided for the truck. i .st:Sq wu x The driver

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-t h: t d-th= rert S: 'rd b :h;d into the switchyard to fuel the machines in this area _ Or thi.,;,;r-d g he pulled straight in, /e checked the welding machine that was ip the

area, and found that it did not need fuel.

He CckufiENIA-the fuel truck and was in the process of backing up when he hit the. support holding "C" phase insulator for the RAT 1A. The insulator and line fell to the ground,vand the transformery {id tripped. 9g I ~ (. 3 92PRCMECT 057721

i At 0820 CST, both RAT 1A and the Unit 2 Train B RAT H1 Side and l Low Side breakers tripped causing a loss of offsite power condition (LOSP) to the Unit 1 Train A Class 1E 4160 volt Buss (1AA02), -emt t he Uni t 2 Train 8 Class 1E Buss (28A03), and W 80 volt busses supplied by 1 AA02 and 28A03. The Unit 1 Train 8 Class 12 4160 volt buss (18A03) also lost power since RAT 1A was feeding bot;h Trains of Class 1E 4160 volt busses. RAT 18 was out of service for planned outage work. During this time, i Non-1E busses fory, Unit 1 were energized through the 230 kV j Switchyard to step-up transformers (step-down in this case) to the UAT to Non 1E b' sses. INA01, 1NA04 and 1NA05. Unit 2 was in a u normal electrical'al.ignment. The ESF Actuation System Sequencers Generators.j and'sent a start signal to Unit actuated upon LOSP 1 and Unit 2 ~ DG1A"and DG28' started and sequenced the loads t Diesel to their respective' buisse's'.v ' (Further description of the Unit 2 event is describe'4"hME0[M(j@r'.MLEk50425/1990-002.) ~$@ti l After DG1 A started *"and sequenced the loads to the Class bus 1E,Uhiag% _1 minute + zu~ sm.w a yJf-" th: b ::Er-c' err;, i tripped.- This caused ange. voltage (UV) condition to classJL, bus 1AA02

e. l'g.'Ihe UV. s 'ghal is a maintained signal *[DGfA

) starting log c rece Nes#thTs signal and relays R-4A, TD2A and I SOL-202-1A (ac't fv'a't'e'is$UE-dowhs ) energized. Since DG1A was t coasting down f'r'oal' thy t' rip',.".tho' shutdown logic did not allow the i I DG fuel ra' cms"o'rj$$Tirid' aTr# solenoids to open and start the l engine. T h i s '! 'c a iIsid ', We "en M ife s t a r t i n g logic to lock-up, a deenergiz#^{dQForTthil Efason,tha? eWsted MF13f the UV sig i condition and relay TD2A e DG1A did not re-start by i' i tself af tse itti-{pped'W.'*MG thetrip,Mf.ZIOdk%d", }. N b operators, were dispatched to the Engine Control After i Panel to investQat'e'thePe~aDse 'of the trip. According to these-operators, seIe'ra M n'n'u iyojs. were 11t. oed fithout fully evaluating themy ene;ohe}a' tor s. reset the annunciators. j On the ~ 'Toltage balance relay was al o found to be ~ j generator panel. i actuated. Durih6 e's' Mm'a ' 'a* Shift Supervisor ( S) and Plant Equipment Oper"a'tokP'E To the s.equencer panel to find out any prob 1' ems"were"' d wen pushed the UV rhiie'tib'$preserittP AIter pushing the reset button, the ~ 1 A's equerice r. The SS quickly if ttoW: SS reset tho' sequencer #bkdine'neigizing and energizing the power thejQaic6i_a[n~6]ahy f,This supply to caused the TD2A relay to an'd meeYithe permYss'1ve for starting air solenoid doenergize to for'a'rEhY]WEeEh'd's]ithe DG tripped the energize-hich caused the engine to start. happened [ inulis[agerf first time. engine: 'st{ar This a Q the, sequencer sequenced the loads as l The cond@jt3[me:?g It did not di t,e andf10 seconds, the breaker and the designed. fAfti engine tripp start back due to the enance[.forem{anandthedieselgeneratorvendor b'1[oc eQs described above. At this

time, s t a r,t ing 1 cig i, o pe ri,t o rs,'~ ' a ma repr esentative'"wgQe!

~ res,s,urg [Q.gnnu. om The initial report was that the Jacket wate,rj p nciators were the cause of the J t r i p.e.r - The3 ma ,o and vendor representative ~ ile wet, reman enanc observed th'5t 'jofp.ecDressure atD is 6 PSIG and the alarm setp the gauge was about c ( 12-13PSIGM.Q .' is 8 PSIG.% Al ont room obser ved a lube oil sensor .3 .if.. i". Ji.Q &.f.- ,t,- ...O, 'vy 92 PROJECT 057722 m.m w

L malfunction alarm. Fif teen minutes af ter the second UV1 A trip, DG1A was started from the engine control panel using the emergency start breakglass button. The engine started and loads were manually loaded. When the DG is started in emergency mode, all the trips except four i j are bypassed.

However, all alarms will be annunciated.

During the emergency run, no trip alarms were noticed by the personnel l either at. the control room or at the engina control panel. The only alarms noted by the control room operator assigned for DG i run were-lube oil pressure sensor malf unction and fuel oil level {' fiigh/ Low alarm. j DG1A ran until 1157 CST, supplying power to the 1AA02 4160 volt t buss. At 1040 CST, RAT 18 had been energized to supply pow to ~ the 18A03, 416_0 volt,_ Class 1E Train 8 buss. At 1157 CSTy 'AT tied tope 1 AA02 by was CT }A L g Site Area Emergency was declared at 840 CS due to a loss of all of f site and on site AC power for mo an 15 minutes. The Emergency Director signed the notification form used to inform of f site government agencies of the emergency at 0848 CST. The ENN Communicator then attempted to notify off site agencies using s the -primary ENN to Georgia and South Carolina.

However, the primary ENN was inoperable due to the loss of power.

Th6 primary ENN receives power from A Train 1E buses which were de-energized due to the loss of electrical power event. The General Manager 6 N. made an update to the notification form at 0856 CST to state that esy.q t power had been restored at 0856 CST. e, wr61 The ENN Communicator then went to the South Carolina backup ENN 0/O' I and established communications with South Carolina agencies b b '. (South Carolina Emergency Preparedness Division (EPD), Savannah River Site -(SRS),

Aiken, Allendale and Barnwell Counties) at g;g//p approximately 0858 CST.

Initial notification of the emergency to these agencies was completed at approximately 0910 CST. The #8 W f ; Georgia Emergency Management Agency (GEMA) was contacted via og/ afi l commercial telephone, which is the designated backup to GEMA and l Burke County

EMA, at approximately 0915 CST.
However, no notification message was transmitted during this contact, because of communication confusion.

At the time the Control Room ENN communicator contacted GEMA on the commercial telephone, the Tecnical Support Center (TSC) ENN j Communicator was confirmfng the operability of the primary ENN to t Georgie, and South Carolina. The ENN in the TSC was operable ] because it received power f rom the Security

Diesel, which was operating properly.

The commercial telephone contact between the 1 control room and GEMA was terminated because both parties assumed the notification would be transmitted via the ENN. In fact, the TSC ENN Communicator did not have the notification forms and could not pass the required information. Attempts by GEMA to ) obtain the notification form information were successful at 0935 a 'l CST when" South Carolina Emergency Preparedness Division (EPD) sont GEMA the notification form via facsimile. Plant Vogtle ) 92 PROJECT 05W

established communications with GEMA at 0940 CST and passed the notification information successfully via commercial telephone lines. Subsequent notifications were made without difficulty. 1 The initial notification to the NRC was made at 0858 CST by the Control Room on the ENS. Subsequent updates from the Control Room and TK were performed without maJoe problem except for a hardware problem on the NRC and which caused them to drop of f ths line occasionally.~ .y..- The primary means?,of notifying on-site personnel is via the plant 5 public address'syst'em (plant page) for personnel in the protected ~ area and telepho'no calls to key buildings for personnel in the protected area ird al:;ba-a=11= ea '=y h"41rHnne for nere

L outside the prote6ted area but.in the owner controlled area.

In minor exception lTnotifications"yere made successfully with a

general, these few
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.,.'.t.. page}l announcement of. the site area emergency was ' ' ~. M '- r The plant made 0901 CST. 'd I was heard in all of the protected area at t except insidecontairEm(ieseTbuilding:ffPersonnelth".on the tyrbine dock of the and in t h e~. d' in these areas were notified by '.'inf' rmY1I rieans '(worR of mouth, supervisors, observing d C others leavi,ng[Tr7a page announcement

  • Tste.')l wi, thin approximately 10 minutes of the area were notifle[.%'.Po'rs"onneT(-in buildings outside the protected by"telephl: ires ~l: alls f rom security by 0917 CST.

d.ENkk.hd, '$MMY.[ The delay in mahinga' he plant:.page announcement, fg;om emergency I declaratiorQ*'atij~0f'40' 'to ' 'pags" announcement at

  1. 601, caused emergenc). f ac'1MtyPa, ctivationf.[!

to be delayed ^a r r' f c.,r f. I1 ' P P'"A '. M., .Q qg%jp' minIJtesbg =4a"*- be is, i was at'mid ~1o{op w % $. p. '4f. The plant ~ hen-the event occurred. Several work i orders were in pIrYogre'ss atItE5 7 time. Instructions were given to complete the foll Tow'1 hip tasks"ph.ior to leaving containment: l' u y Nt. 1HV-8808D. & hYty.M h dnE &t. Q e% M.," a) the SI Acc,,yeassembly. and bonnet bolts, 6inGTa't'or #4 1sh161oh 'va'1v'e. t i g ht en ifrg,. This is b) Complet al t onI hSteam Generators

  1. 2 and
  2. 3

.n. ..>...,~~c.?.. manways .--A Cl os e.8.. .u.7ft. c-i k I c) ",._ t h pment hatc and reinstall the interlocks on l the p $ ersili a1E-lo'ck 'V. M 4 All work'.w accomp]31 'en maintenance personnel exited wa containmer'itf~ 0151(iCS W i . ' a. The supp1h rea ers@ h u l d'~ E}u ii*'. 1AA02 and 18A03 were or."C ass;1E busses moved so t E R'A power. .+-

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'.t .g.;e. 92 PRCUECT 057724 y. t

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& M U.t. s. Shortly after the Loss of

Power, the Operawiwi Shift l

Superintendent directed the Manager of HP & Chemistry to evacuate cont Aaent in a controlled, orderly manner. He also directed t efDutagesano r sammng to " button-up" the mid-loop worked ~ he pressurizer manway w e left off to provide a RCS vent g path. T he Or= e = *len-S hi t uperintendent realized he had given conflicting. instruction to the Manager HP & Chemistry and Manager Outage $& Planning. The rope ra taan. Shi f t Superintendent called the Manager HP & Chemistry back and informed him of the work that was to continue inside consinment so that no: all personnel would ba ~ evacuated. A communications error led t.s Manager HP & Chemistry to believe that all RCS

openings, inuluding the pres suri::er

.~ manway which was not specifically discussed, should be securad. . Power had been restored and RHR cooling re-established when it was announced t_ha t. t_he pressurizer manway was secured. The General Manager (""Wh6"Ey now had assumed the ED Position, decided not to remove the manway because the plant was stable. The announcement of the emergency advised that a Site Area Emergency had been declared and that all visitors and escorts should, report to the Plant Entry Security Building (PES 8); and all emergency response personnel should report to their emergency response facility. The prescribed section of the initial announcement from the emergency procedure ccncerning evacuation and assembly was purposely omitted. Therefore, neither a gytal site evacuation nor assembly and accountability were TSr/dt m s ed. The decision to omit this section by the dbergency gNrector was based on there not being any immediate radiological danger to the I plant personnel. The omission of the evacuation and assembly announce' ment caused confusion on the plant site because there were no instructions for non-essential personnel. Some personnel stayed at their work

location, some personnel exited the protected area and assembled in the Administration Building and parking lot area for accountability, and approximately 200 personnel relocated to a relocation center located about 1 mile from the plant.

Another public address system announcement was made at approximately 0917 L;ST stating that the emergency had been downgraded to an " Alert." status and that all non-essential personnel were to assemble at the Administration Building parking lot for accountability. Some personnel already located in the Administration parking lot area did not hear this announcement due to public address :ystem inaudibi ity (apprsximately ?nn_ -perconnel neported). Therefore, no ' nformation was given to t hes e people. Many personnd considered themselves essential, and therefore, re-entered the plant protected area. @i ( ~ hb i 7 92 PROJECT 057/25 g'

l [ Sccurity notificd tho event was downgraded to an Alort, rolocation center via the Land Department. Land Department l Once the then told all personnel at the relocation center to go Plant personnel returned porsonnel to the site and return to work. The Security Department at bcck ond some entered the protected area. for all non-made two public address announcements J in cosential personnel to exit the protected area and assemble ) t hi s time made These announcements were the Administration parking area. to aid in conducting' accountability. v-heard the Site Area Emergency plant page ^ The Security Department 0901 CST. At approximately 0912

CST, and tone at It was

.,cnnouncement badge accountability report was obtained. "the initial inside the protected area determined that the're were 19 7,'. persons not' badged..jnto one of the Emergency

Response

(PA) who were Facilities (the Con't'rol. Roomp. TSC and OSC). i -p.c ::;-reg .. yh - -.. w ...- rs. w was 0920 CST 7. the second badge accountability report there were 133 persons about Atinitiated. Upon completion of this report, not in one of the Emergency inside the protectiedf are~a7but Re s pons e F a c il i t i es.fc...,, :$. t.l. d..,'. J'. FQ480 ~ 't.D.'Ah'd ' ba d g e a c c ou n t a b i l i t y report was 0940 CST,- the th.r i

report, there were 120 At about initiated.

Uponl j completion,[^'of.' this

  • 'c'counied for.

A fourth and fifth nbt". person's that ; we e%'"Vcbndd'cifecfat 1000 CST and 1130 CST with 97 a cccountab111 ties'I,t[$~ h h$$b?lbh h 5 wer and 49 persons riot a'Ehblurdecf,To'rf respectively. >:$h Power Company ses were made.,odt of the Georgia News media relea corporate'of f3ceQh'Operatin[g Company (SONOPCO)Ga[w

tlanfa, Project office in Southern Nucleard.

r'ocess that SONOPCO uses to release, 81 cming ham',j,A. lab $p}Z jhe%s.d f ollows : i tiie7mediajis. a inf ormation to&E&N.CQ'f a' irs"(PA) personnel are notified &E' upon The SONOPCO public~ af activation,off the. Gede'ra'i,6f fice Operations Center (GOOC) by ~ the G000 Mana'ger... Upori~ not'ification, they report to the T'. O.U ?e I, 9 y GOOC. ., w ~ n.c 3 j 'GOOM ' $$ahM."[s$ stis" public affairs personnel by c technical The providing {plantje 'st7atydhformation coupled with 1 prepare draft press releases. assistance as. the. PAf, eson . pn. 9 > wq,;;+ ,.3 en approved by the Project Vice w The. press. releases a iidr Ey. Manager and transmitted to the {CQ'upeg['s bf Public Relations in Atlanta by P r es,1. din't S Georgia owe fupagy,do ,f, Public Relations then transmits t eslecoph Supervisor t he[ priss, e, mas'uq e, site Public Relations and.to med rsonne ? N.Q&$ d by failure of the telephone bidg~e statusE lo$.t e GOOC was,' ampere ly COOC personnel established Plant. status to ~ p t: T o b 7p~r; o p;u a. separate phone line to obtain 'wi t 'h r C ' communic,ation's , plant status ~. ~. y

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-g'= ": 92 PROJECT 057728 yy 's b a.

l b) The root cause for the failure of DG1A has not been conc 1 voly determined. The two trips that occurred during this ent occurred at 1 minute 20 seconds and 1 minute 10 seconds af ter the DG tied to the bus. There is no record of the trips that were annunciated af ter the first trip. The cause of the first trip can theref ore only be postulated, but most lik,ely has the same root cause.as the second trip.. An event review team worked with several on site' and vendor diesel generator experts to develop a detailed test plan. While the completed test plan provides significant evidence for the most likely root cause of the second

trip, further to provide crad M,gy+ y fedT postulated sequence testing will be conducted the Engineering Support

^ Department of events that caused the first trip. The second trip occurred at the end of the timed sequence of the group 2 block logic. This logic provides for the DG to I come up to operating conditions before the trips become active. The block logic timed out and the trip occurred at about 70 seconds. The annunciators observed at the second trip included Jacket water high temperature along with other active trips. It is believed that the Jacket water trip is the most likely cause of. the second trip. In conducting the event review team's test plan, the trip conditions that were observed on the second DG trip on 3/20/90 were essentially recreated by venting 2 out of 3 temperature

sensors, simulating a tripped condition.

The recreation duplicated both the annunciators and the 70 second trip time. This most I likely cause assumes Jacket water temperature sensors with setp61nts below the normal trip level of 200 degrees F existed and resulted in the trip condition. This trip condition caused by the keep warm system and sensor setpoint variance could have existed on DG1A, and did in fact p exist on DG18 at the completion of the 36 month DG outage testing. A Jacket water keep warm system operates to 1 .j maintain a Jacket water temperature at the engine of about 165 degrees F. An immersion heater in a standpipe with a separate heater control element maintains the temperature. On DG18, the control range of the keep warm system combined with the actual setpoint of the Jacket water high temperature sensors resulted in these sensors being found in a tripped condition with DG1B in standby during the maintenance outage. Similar circ'umstances are suspected to have occurred on DG1 A. The event review team's test plan did not duplicate this most' likely root cause for two possible reasons. The UV test ~ conducted on 3/29/90 was preceded by an air roll of the diesel. This air roll, which also causes the engine's shaf t driven Jacket water pump to run, could have partially moved some of the relatively hot water from the bottom of the standpipe into the piping where it cooled as the pre-start checks were being completed. The second possible difference'. = ( is in the control of the Jacket water heater elemant. The Jacket water keep warm system cycles the heater off and on to

  • c y'

s 92 PROJECT 057727

1 . maintain temperature. The event of 3/20/90 could have occurred with the Jacket water system at its highest i temperature, and the UV test run at a lower Jacket water temperature.. If follow-up testing is unable to confirm these potential causes for the DG trip, a supplemental LER will be submitted. '.;.., f~ 3.3 Contributing, Causes .. g y. c) Plant conditions"were inadequate prior to the event. Two of four sources of' class 1E AC power were not enough to ensure plant protec'tficing in'. light of the event which actually occurred. Procedures did not sufficiently address loss of RHR during outfags c"ohditions or rapid closing of containment and ~ RCS openin'gs duping outage' conditions. ..W;*k$YbY.N$}}$5MO-d) The flow. of informatiorV to the GOOC was inadequate due to 4 loss o f., 'the leliphone' bridge lines. Information was not 7 veFidibWan'd this led to the inaccuracies in the easily press rale la'sEL l blip.yT;3M..,y. fl'$+ M {., % 5 . cation %'were.i'~ e) Of f-s i te'_ not s inadequate. Georgia agencies were eT15acN3p'i'put into use at not a p'a'r t" 'ENN because in 1986 the back-up ENN ore. k7a plant Vogtle. A was.repla'c decisioitTas ma'ciEW th,itt'ime ' that since a back-up was not requi recf "t~ YasYrfot n'icessary to add the two Georgia agencies"s'inc hoyCicSDTcl~be notified by commercial phone N-lines if"th'IPp lie fjEN N a ~

Thus, the commercial phone i

Georjia*a'gd(he aga'tGTe tifet e 7 b h c % [ l ie' d lines deMs notification system for the two of this event. The Emergency x communicati,%gtfsQhThin..the importance of prompt of f-site Director %d { o g apddid pt.' ensure ongoing communications with outsidin% Q gencl'e's Ai:Icii tionally, the Control Room i commun'icht,o g f8]o, t(i[allyunderstandthefuntioningof the back'-up anci tornate-systems. Emer,.[ fghih39ff ~ h T m. ge.nc 3_esponse 4 Fac111t':y. (.ERF) computer did not f) The-I provide. &cE6cate*f' hinEffcal.' dat'a to ' personnel in the

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Operatio'nsT 8'uhMrE' C"d'NEeE.(OSC) and Emergency Operations 4 Center, (E.O. f.)Me8 abs ~'@ bf."a; component failure of its data concentrato ./ l .:a}E ,.,,.. 'n '~ g) Accounta . ~ norg' essential personnel was not properly anWvac"u' t' ion was not ordered and there was s conduct d cau .5 no'c1'sa r}},c,u ,,,.T[ementationwasinefficientngof.whowas'orwasnot ess n i The Emergenc in that the re E2Fsee that. clear and explicit Emerg'e~nE ' ~ E fdeviating from Emergency Plan di rec'tH'cin W von procedure p_o or e n an evacuation when the Site Area i Em'ergenEye war eclar. "bc !. , f. A.* ...wm[>.:/,c.r. .a, ;w .. 3 " $- M h f d h M. % m p.%..; . c.dg 3 +. ~ i; (-..x.. ~. ., v.. n x< g.nt.. n.p q.,., ;- ilh '-c D. e.n,,y.4 qs ir . w w,,q~. :. n.s. n. e; n g,_,.: u...,. .. r :.,..

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\\ e l 4. ANALYSIS OF EVENT Unit 1 was in Mode 6 aproximately 25 days into refueling, with i safety related Train "A" providing decay heat removal. The primary system was at approximately mid-loop and steam generator i primary manways were~being installed. The loss of offsite power i to the Class 1E buss 18A03 and failure of DG1A to start and i operate successfully, coupled with DG1B and RAT 18 being out of ] service for maintenance, resulted in Unit 1 being without AC i power to both Class 1E busses. With both Class 1E busses de-i energized, the Residual Heat Removal (RHR) System could not perform its required safety function. DG1A was manually started within appr'oximately 36 minutes, after l t two trips, and Train "A" RHR, Component Cooling Water (CCW), and i Nuclear Service Cooling Water (NSCW) were re-established. Based l on a noted rate of rise in the RCS temperature of 16 degrees F, j measured at the core exit thermocouples over a fifteen minute

period, the RCS water would not have been expected to begin boiling. until approximately 1 hour and 50 minutes after the beginning of the event.

Based on this RCS water temperature and l e' review of expected results of a loss of RHR flow, the fuel and i equipment is expected to have remainedtwell within design limits. .,x'at a m l ",'The's'Eeam generator primary side manway installation and closurs ~ j o f,,y then containment equipment hatch were completed after re-i establishing RHR,. both well within the estimated 1 hour 50 j minutes, prior to the projected onset of boiling in the RCS. A review; )of,information obtained from the Process and Effluent Radiatio . Monitoring System (PERMS) and grab sample analysis indicated,. all normal values. As a result of this

event, no significant increase in radioactive releases to either the co.n.t'ain' ment or the environment de b-1da"=d
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'--= occurred. . n. . u Additional systems'were either available or could have been made ava11ab1e to ensure the continued safe operation of the plant:

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1 ~. ' T ho' maintenance on RAT 18 was completed and the RAT returned to seryice approximately 2 hours into the event. 2. Offsite power was available to Non-1E equipment through the generator. step-up transformers which were being used to "back-feed" the Unit Auxiliary Transformers .T[. (UAT); Class 1E busses M.'lgh.,1 AA02f.;and supply the Non-1E busses k: ,and. 18A03 could have been powered by

feeding,

'M;; [M:through.Non-1E bus 1NA01. 3 .,,.s.._- ,.1-r,;.?_; - $y ".. T.g.

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33,i.T The' Refueling Water Storage Tank could'have been usedh , ;/5 'c ~ t o manually establish gravity feed through the RHR-7 5; 73g and/orl, Chemical and Volume Control System (CVCS), and2 (.3 gig. SafetyT, Injection (SI) to the RCS to maintain a supply 2. ( a ' 13 3 2 of cooling water to the reactor. 7.k

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~_- i. b l Consequently, neither plant safety nor the health and safety of the public was adversely af f ected by this event. 1 ~ f mo7w---NiiIta11ed, assessment of this event and an assessment of potentially more; severe circumstances will be performed and Judedinasupplemefal,'LER. ..$2*05.L.E.".?- CORRECTIVE ACTIONS'.k..,w ;!;.d. ( & gr.ed yV ANW l#U 6$ .. ~;;r.(. I F. k

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'.i N f.,.. M.:.t Q.-eMg '[ v v : .s. r. a) /U D' J trucCdr3eh 1(%'r5s's"r;e,,. i 1)Onsite ce quirements will be changed to i match state, r.$qu1rjrEs[t'bj%~ training s 5 g skz,,,g.f, ) 2 )Secur i ty'*r, of fj cers3'f ' escort will Ae safe e e'lis ) l operation'Isf 3)Sens' tivega@n.if%g$,,d a i i i u ia .o r ea s.' inside the the protected area will be evalua. -.i an 4 ) An e'ngi ne,'e@rn.ng pprop ate barriers erected or controls tec establish jf~ l ng. ns. u.eator support structures will be l c o n d u c t e d - d..&r,.,,.o,.w o u g. ,an.chen es ma y necessary. l c' < l. l$$ (&;~ 't >~.b. pus) ) d R. { b) m.. V v { 1)Investiget on n -cause ' of. the diesel, trips will p @' c o'n t i nu e r, 6 i ~ 2.) Pe'r s onn el. n. -. a. .r.di>1 a c ement of the currently i e u i n s t'al l ed-3)The Loss,,f~a.seg.sensops .,more reliabia design. j 1;OS,P) diesel start and trip logic j owe .w4-1 'I M: b'e t = m so ta automatic emergency start-will i . occiuir Mp'[ C05' ~ l 4 )DG ~.ohepa' ting roce r be revised to include restarts foi1'dkin' R Wi ,E: }} Y Pfo 5 ) A..i evie.w or.f 3:onduYng'a.nd installation of' i _a diesel 4 logic. boa. T..e1 ncted.. to. improve logic board i rel i'ab il t '7p!~' { '6)Operatsch (T(c,an~c ,o 4r,ecor' ding ' " pertinent alarms and inchta tions n eve'1'oped in order to assist in i nves.t15'a E1on uTT' a 'aEerit'sy. /4 Aj,/.ca, J/ P/*fb l incr......i 7)When:. DG 9 e D.e. ^ 9,the.' test frequency will be ) .=.

..in accordance with Technical ease onc ve y syst 1

7.. ' Shec'i u n t i l.f.1.h'.a t.o9 8-his continued N. tests,. frequency will be ~ ~ d are completed and and one or consecu 'le'ss':.Iva}i@thess wowe'W. -fDurels;Ithere have" been a total of l EcIIg d"in' the last' 20 valid tests. Inc Gd'irig ..n. y s? y..g :.rafou' rival 1 M 1U s p' 4 ~ is a fftesis' of DG1 A>

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4 h 92 PROJECT 057733 e-i s . + -. r. - -

i The first press release contained two errors.' The first error was in the time of declaration of the site area emergency. This occurred when the General Manager called the project Vice President and indicated that a/ite/rea emergency had been declared. This was the first indication for corporate personnel that a site area emergency had been declared and the time of the call was approximately 0900 CST. Previous notification by the site duty manager to the corporate duty manager did not indicate that activation of the emergency plan had occurred at 0840 CST. GOOC personnel assumed the Site Area Emergency had been declared at 0900 CST. The second error stated that "non-essential personnel were evacuated" and should have stated that non-essential personnel were evacuated from the protected area to accomplish site accountability.. This error resulted from a mis-communication between the plant and GOOC personnel. The second press release contained only the time error. No further press releases were needed due to the press conference held that afternoon in the Atlanta corporate office. By 1200 CST, plant conditions had stabilized with off site power restored to Unit 1 and RHR established for core cooling. The Emergency Director initiated a conference call with local government agencies (South

Carolina, Georgia, Allendale,
Barnwell, Burke County and SRS) to discuss termination of the emergency.

The Emergency Director also discussed termination with the NRC. Agreement was reached with all parties that the emergency would be terminated. The emergency was terminated at 1247 CST and all agencies were notified by 1256 CST. 3. CAUSE OF EVENT 3.1 Direct Causes a) The direct cause of the loss of off-site class 1E AC power was the fuel truck hitting a pole supporting a 230kV line for RAT 1A, which caused the loss of the off-site power sourCS. i b) The direct cause of the loss of on-site class 1E power was the failure of the operable DG,

DG1A, to start and load the jpg) l LOSP loads on bus 1AA02.

,gp } ffarif NM 3.2 Root Causes gef u# a) The truck driver met all current site training and qualification requirements, including holding a Class 2 Georgia driver's license.

However, to drive the same truck on state highways would have required a Class 4 license.

The site requirement was therefore, inadequate. Furthermore, site safety rules require a flagman for backing vehicles when i viewing is impaired, as was the case on 3-20-90. This rule ( was ther:f ere violated. 92 PROJECT 057734 9 -}}

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