ML20100B764

Intervenor Exhibit I-MOSBA-111,consisting of Procedure Number 00057-C Re 900711 Event Rept Entitled, DG 2A Start Failure

ML20100B764
Person / Time
Site:	Vogtle
Issue date:	10/11/1995
From:	GEORGIA POWER CO.
To:
References
OLA-3-I-MOS-111, NUDOCS 9601230132
Download: ML20100B764 (25)

Text

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) moccouae No. nevision paae no.

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DOCKETED T-M 6 M '7 #/ sheet i of 10

USHRC -

'95 OCT E M0 SHEET 1 Exhibit.d ,pqe_._ ofM a

Report: Page -

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OFFICE OF SECRETARY 00CKETING & SERVICE BRANCH 1

EVENT REPORT 1

EVENT TITLE: DG 2A Start Failure

REPORT NUMBER

2-90-005 I

DATE(S) 0F EVENT: 7-11-90 EVENT CLASSIFICATION: B -

Names of EVENT REVIEW TEAM MEMBERS Ed Kozinsky George PrecericK Paul Kocnery Ken 5 totes charles coursey Joe D' Artico Signature of EVENT REVIEW TEAM LEADER ,

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DATE COMPLETED 7-19-90 4

MANAGEMENT REVIEW AND APPROVAL N PRB Review Required YES NO []

! FRB Chairinan

Meeting No./ Date NUCLEAR REGULATORY COMMISSION 7882228aN osa8al24 - *" ~ 2 * > = -$ ="= "o S "'

q pgg in the matter of Georoia Power Co. et al., Voatie Units 1 & 2

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. O Statr O Applicant Sintervenor O Other O ldentified s(ieceived O Rejected Reporter FD

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= MIOCEDURE NO. REVIS60N e' AGE NJ.

5. VEGP 00057-C 5 29 of 37 l

, Sheet 2 of 10 DATA SHEET 1 Of-l Exhibit _ ,page Report:

! Page 2 of M %

{ TABLE OF CONTENTS FOR i

EVENT REPORT NO.

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1. REPORT NARRATIVE (PER SECTION 4.6) . . . . . . . . .

2. EVENT DATA COLLECTION . . . . . . . . . . . . . . . .

3. CHRONOLOGY. . . . . . . . . . . . . . . . . . . .. .

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4.** PERSONAL STATEMENTS . . .(Figure 2) . . . . . . . . . '

j 5. ROOT CAUSE DETERMINATION (PER 00058-C). . . . . .. .

! 6. ADDITIONAL SUPPORTING ITEMS . . . . . . . . . . . . .

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ERTL TO NUMBER EACH PAGE OF THE REPORT AND ENTER APPROPRIATE PACE NUMBERS. ADDITIONALLY, THE ERTL WILL ENSURE THE EVENT  :

REPORT NUMBER APPEARS ON EACH PAGE OF THE REPORT.  !

i INFORMATION WILL BE PRESENTED ON THE INDICATED FIGURE.

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UNIT STATUS

Unit 2 was at 80% power at the time of the 2A diesel start failure. Unit I was at 100% power. No equipment related to the 1

diesel test out of service.

EVENT DESCRIPTION On July 11, 1990, diesel generator 2A was being tested during a routine surveillance per procedure 14980-2. The right air bank was isolated for the July test of the left air bank. When the

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engine start button was pushed by the control room operator, the engine began to roll with starting air. The engine rolled twice and stopped, according to the local operator in the diesel j room. The engine failed to start. The diesel was declared

, inoperable and the Technical Specification action statement was

. initiated.

On July 5, 1990 a similar event occurred when diesel generator 1B failed to start. The causes and corrective actions of this event are consistent with the DG 2A incident of July 11, 1990.

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TROUBLE SHOOTING The seizing of these air start valves was discovered by a " pop test" perfomed under the manuf acturer's direction. This test applies approximately 100 psi of air to the starting air valve at the engine subcover. An audible sound can be heard on valve opening and closing, if the valve is not sticking. All valves initially noted to be sticking were machined to a tolerance of 0.002 to 0.003 and retested with no problems found.

The engine was started and loaded to 100% and maintained until temperatures stabilized. The " pop test" was re-performed with seven air start valves still indicating problems. One cap stud was untorqued during cap removal for inspection when we heard the piston pop open. A few other caps were loosened with the same results. All caps were removed on the problem cylinders and placed on a true flat surface. Some were found to be warped and all had irregular bore surfaces. All caps were replaced and pistons machined to approximately 0.003.

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ROOT CAUSE:

Diesel generator 2A failures to start due to starting air valve piston seizure within its associated cap assembly appears to be the result of marginal clearance between the piston and cap.

This condition exists apparently due to manufacturer machining process which allow uneven bore conditions on the cap and in some cases caps with flanged surfaces which are not flat.

, Secondly, the tolerances specified by the manufacturer were 0.001 to 0.003 between piston and cap. This clearance may have been sufficient for ambient temperature but did not allow for d

expansion of the piston inside the cap during engine standby or l operating conditions or to overcome any machining irregularities.

The event critique team determined that ineffective corrective

. actions exists with respect to the ability to resolve Diesel Generator start problems. The July ll, 1990 start failure of DG 2A was the fourth occurrence of this problem. A troubleshooting MWO had been written but not yet implemented. The third failure of DG 2A occurred on April 20, 1990. An event critique team was not convened after this failure contrary to the policy established as a result of the SAE event critique.

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'. I CORRECTIVE ACTIONS All Diesel Generator 2A air start pilot valve pistons have been verified to move freely inside the cylinder walls. Pop tests

are to be performed immediately on Diesel Generators 2B, 1A and IB to demonstrate freedom of movement. Any sticking conditions l noted will be appropriately corrected. Additionally, Maintenance Procedures 28714, 28713, 28575, and 28576 are being revised to include provisions for pop tests during each refueling outage.

To minimize the possibility of sticking, Engineering is assessing the gap minimum clearance distance between the piston 4

and cylinder walls. Any changes in the desired minimum gap  ;

3 clearance will be reviewed against recorded gap distances for

Diesel Generator lA. 1B, and 2B for possible replacement. Also, changes to the minimum gap clearance will be incorporated into [

l Maintenance Procedures 28714, 28713, 28575 and 28576.

1 I During the next scheduled tear down of Diesel Generators 1A, 1B, l' and 2B, the surfaces of the air start pilot valves will be checked for machining irregularities that could lead to sticking conditions. Replacement or reconditioning will be performed as necessary. ,

To correct the problem of ineffective corrective actions noted

. as a result of four Diesel Generator failures to start, the event critique team recommends that the policy of having event critiques for Diesel Generator failures should be continued

. until plant management determines that Diesel Generators are sufficiently reliable. This policy was established as a 4

corrective action from the 3/20/90 SAE event.

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j- IV. ANALYSIS OF EVENT Diesel Generator 2A is one of two independent power sources that provide power to class 1E busses. During the time the 2A .

' diesel engine was under investigation, the redundant 2B diesel l generator was capable of performing its intended function The i plant entered an action statement for technical specification I

' 3.8.1.1 which requires initiating a plant shutdown if the diesel

cannot be made operable within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />.  ;

r Prior failures of this engine may not have been fully investigated to ensure the causes of the failures were found and corrected. The results of this investigation indicate that there existed a manufacturing or installation error that resulted in deformed air start pilot valve cylinder. The deformity revealed itself in a random pattern. The effects of the deformity could only be observed on an engine start after the engine had been shut down from a previous run and the engine stopped with a particular combination of faulty pilot' valve and crankshaft position alignment. There were a total of 7 cylinders with questionable air start pilot valves.

On a normal attempted restart with the air start pilot valve malfunctioning, the 5 second burst of air was not adequate to start the engine rolling over. The burst of air was adequate to change the alignment of crankshaft position and faulty pilot valves so that any subsequent attempt to start the engine would be successful.

Based on the availability of the redundant 2B diesel at the time the 2A diesel was declared inoperable and the fact that the 2A diesel should have started under emergency conditions, there was no adverse effect on plant safety or the health and safety of plant staff or the general public.

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PROCf DURE NO. CEVISION DAGE NO.

VEGP 00057-c 5 30 of 37

, , Sheet 3 of 10 DATA SHEET 1 Event Report No. n i

EVENT DATA COLLECTION Report: Page 8 of wh

1. EVENT DESCRIPTION

' EVENT DATE 1 l i i l ot o UNIT 2. EVENT TIME cX"~

otte DEFICIENCY CARB NUMBER 2 -9 0 - m. 7 t J

(IF REQUIRED) '

2. TYPE OF EVENT A. REACTOR TRIP ( ) F. RADIOACTIVE SPILL /

8. FORCED REDUCTION ( ) UNCONTROLLED RELEASE ( )  !

i C. PLANT TRANSIENT ( ) G. LIQUID INVENTORY LOSS ( ) l

D. ESFAS ( ) N. OTHER SIGNIFICANT EVENT ( VT i E. PERSONNEL CONTAMIN ( )

4 1 3. EVENT REVIEW TEAM CALLED OUT: TIME o3co SAER INFORMED: TIME i CORPORATE DUTT MANAGER INFORMED: TIME

4. DATA COLLECTION ASSIGNMENT 3'D wiu e.w %

i i S. DATA: FOR REACTOR TRIPS COMPLETE 10006-C. AND GIVE A COPY *0 THE EVENT 4

REVIEW TEAM. FOR ALL OTHER EVENTS, COMPLETE THE SECTION 5 THROUGE 16 AND PERSONAL STATEMENTS. .

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STATEMENT ,

ACTIVITY PERFORMED ATTACRED '

SHIFT PERSONNEL AT THE TIME OF THE EVENT TES OR NA l

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h x t a c_ h.n L-d J/A i Utar.RS INVOLVED~

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A . %c ct- c_, - a P tw N E. $

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DATA TO BE COLLECTED (SRIFT SUPERINTENDENT TO CRECK ITDtS)

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1 4 NOTE: REMIVE THE DISE PACE AFTER A TRIP /SI. '

2 PLANT COMPUTER ALARM PRINTOUT ( ) PLANT COMPUTER EVENT LOGS ( )

ATSI PRINTOUT ( ) ERF CCRIPUTER EVENT LOGS

( )

FAULT RECORDER PRIFTOUT ( ) ERF COMPUTEP. TREND PRINTS ( ) -

' r'RART RECORDERS (LIST) l COPIES OF:

l NPC-OC NOTT.rICATICN WOAASREt.T t >

035 LOGS ( )

TUR&INE BLDG LOG AUI BLDG OPERATOR LOG ( )  ;

' ( ) RWO LOG ( )

CONTROL BLDG OPERATOR LOG ( ) ELECTRTCAL IAG ( )

Otrr$IDE OPERATOR LOG ( ) UNIT CONTROL

, CEENISTRY

( ) i

. RF MWD's

( wet ,

l. NEDtEE NO. REVISION PAGE NO.

. VEGP 00057-C 5 31 Of 37

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. Sheet 4 Of 10 DATA SHEET I Event Report No. , e_4 Report: Page 9 of Te.w

7. PLANT CONDITION WHEN APPROPRIATE MAXIMUM / MINIMUM PRE-EVENT VALUE POST EVENT MODE /

REACTOR POWER / I BORON CONCENTRATION /

STEAM CENERATOR LEVEL 1* /

• Use NR or WR, 2* /

whichever is 3* /

indicating 4* /

GENERATOR OUTPUT / MWE PRESSURIZER LEVEL /

8. PLANT CONFIGURATION 8.1 0FF NORMAL STATUS OF PLANT SYSTDiS A e_ c o '? n p '

ee s 8.2 TESTS AND SURVEILLANCES IN PROCESS l49M - 2 %G 4

n x L x 1, , e , v . F e:T-a

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8.3 OTHER OPERATIONS IN PROGRESS AT THE TIME OF THE EVENT hies a M w S a i;- %u- e i w e i

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9. FOR ESFAS ACTUATION OR FAILURE AUTOMATIC ( ) MANUAL ( N/A (

) )

9.1 LIST CNANNEL ACTUATED / FAILED i EXPLAIN SYSTEN RESPONSE .

l 9.2 DID THE ESFAS COMPONEN!E 0?ERATE CCKAa.CTLYT TES ) , NO (

( )

_ WITHOUT UNDUE DELAY? YES ( ) NO ( ) l 9.3 EXPLAIN ANY ARNORMAL SYSTD( ESFAS RESPONSES. WNYT l

..- - . . - - . . . - . . - _ - - . - . . . _ . _ - - - . . - = . . . .-

. . . ~ . - . . - ..--.- - . - . - ..- .-.. .

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k j PROCEDUCE NO. REvaSION PAGE NO, l' {

VEGP 00057-C 5 32 of 37 l~

- Sheet 5 of 10 l DATA SHEET 1 Event Report No. ., k Report: Page L of D i 9.4 DESCRIBE ANY OTHER MAL WNCTIONS NOTICED: j 1 ,

l 9.5 APPARENT EVENT CAUSE WAS  !

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10. CORRECTIVE ACTIONS i

j 10.1 WHAT IMMEDIATE CORRECTIVE ACTIONS WERE TAKEN AS A RESULT OF THE EVENT 7 i hu. 7 : 2. x .w s + 2 23 c, - 2 rr# - 5,rc Seis a c. J  !

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10.2 WHAT SUBSEQUENT CORRECTIVE ACTIONS ARE IN PROGRESS AS A RESULT OF THE i t

EVENT 7 eco 2 -9c 14$  ;

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10.3 WHAT FURTHER CORRECTIVE ACTIONS ARE RECOMMENDD7 l

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LIST CORRECTIVE ACTION TAKEN FOR EACH ABNORMAL OCCURRENCE OR EQUIPMENT MALFUNCTION TRAT ACCOMPANID THE EVENT (STATE WHETEEE COMPLET E . IN  ;

! PROGRESS, OR PROPOSD).

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! 12. WERE FROCEDURES US D ADEOUATE7 I TES ( ) NO ( )

WET NOT7 i

, 13.

1 DID TEE OPERATORS AND OTHER PERSONNEL RANDLE TEE EVENT CORRECTLT!

i EXPLAIN. DISCUS $ CORRECTIVE ACTION TO DATE.

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. PROCEDumE NO. REVISION FARE NO.

, VEGP 00057-C 5 33 Of 37

. Sheet 6 Of 10 ]

DATA SHEET 1 Event Report No. .

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Report: Page 11 of TE %

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14. WAS AN DEERGENCY PLAN EAL REACHED 7 DESCRIBE LEVEL INVOLVED (NOUE,  !

l ALERT, SITE AREA, CENERAL). l j

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15. LIST LCO'S ENTERED

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i LCO NO. DESCRIPTION INITIALS '

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16. LIST ANT SAFETT LIMITS EXCEEDED. TECH SPEC AND DESCRIPTION I

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i COMPLETED BY: '

4 DATA COLLECTOR

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. . . . . _ _ . ,..- - .. _ _. _ ._ . - - . - _ - . - . . . . . _ . . . . ~ . . . . . . . - . . - - ..

'* N EDUmfNO.  :

ggyggioN PAGE NO. ,

VEGP 00057-C 5 34 of 37

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. Sheet 7 of 10 DATA SHEET 1 Event Report No. ,,

Report: Page 12 o t e2- A. '

l SEQUENCE OF EVENTS CHRONOLOGY DATE/ TIME EVENT '

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PROCEDU,.E NO.  ;;EvtSION PAGE NO.

-VEGP 00057-C 5 35 of 37 4 . Sheet 8 of 10

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DATA SHEET 1 Event Report No. .+

Report: Page 1 of s

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INVESTIGATION QUESTIONS l

A. GENERAL

• 1 i 1. DOES THE EVENT REPRESENT ,PREVIOUSLY UNFORESEEN l t

ACCIDENT SEQUENCE? YES/  !

2. DOES THE FAILURE DIRECTLY OR THROUGH INTERACTION WITH j OTHER SYSTEMS DEGRADE THE PE ORMANCE OF ANY t

SAFETY-RELATED EQUIPMENT 7 S NO ,

l 3. DOES THE FAILURE DIRECTLY OR THROUGH INTERACTION WITH 4

OTHEBd3YSTEMS INCREASE THE PROBABILITY OF AN ACCIDENT 7 l

YES @ /

4 i DOES f THIS FAILURE CHALLENGE OR ACTIVATE SAFETY SYSTEMS?

3 YES QNO '

5. DOES THE EVENT INCREASE THE PROBABILITY OF TRANSIENT OCCURRENCES AND/OR REACTOR TRIPS?

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YES/ @ '

6. DURING THE EVENT, DID THE OPERATIONS STAFF RESPOND CORRECTLY? QS/NO

}- 7. ARE TRAINING KNOWLEDGE OBJECTIVES, PERFORMANCE. TASKS AND CONTROLS ADEQUATE TO PROMOTE THE PROPER PERFORMANCE l QF/fRE OPERATIONS STAFF UNDER SIMILAR CIRCUMSTANCES?

l. (YES/NO

8. BASED ON A COMPARISON OF THIS EVENT WITH PREVIOUS EVENT

REPORTS AND/OR FSAR ANALYSES, WERE THERE ANY ABNORMAL OR DEGRADED INDICATIONS 7 YES @

9. BASED ON COMPARISON OF REIATED SIMILAR INDUSTRY AND i

IN-HOUSE EVENTS, THIS EVENT A REOCCURRENCE OF A i PREVIOUS EVENT: TEJ/NO y f4 Ocm,,., g,,c. e,

10. DURING THIS NT, DID ALL AFFECTED SYSTEMS RESPOND AS l EXPECTED 7 S/NO 1

11. DTD THE INITIAL EVENT PRODUCE UNANTICIPATED SECONDARY EFFECTS WHICH COMPL D OR INCREASED THE CONSEQUENLEC OF THE EVENT 7 YES ,

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-- - . _ . -. . - _ . . .~ - - - - . - - - - -. . - _ - . . ~ - . - -- . - .

I q* PROCEDuisE No. REVISION PAGE No.

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'. Sheet 9 cf 10 I j DATA SHEET 1 Event Report No. x Page 14 of re

• Report:

INVESTIGATION QUESTIONS (CONT'D) i 1

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12. BASED ON COMPARISON OF SIMILAR INDUSTRY AND IN-HOUSE  ;

EVENTS WERE PREVJ.OUS CORKECTIVJ ACTIONS / IMPLEMENTATION -

) EFFECTIVE? 4 FWchA ev5 /0 Aar vem~M 'l h e acRon

13. YESGO',9,,p. ,, (( ge IF QUESTIONS 1, 2, 3, 4', 5, , If'k 11 ARE ANSWERED

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YES, DESCRIBE THE REASON IN DETAIL IN THE EVENT REPORT.

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14. IF QUESTION 6, 7, 10, or 12 ARE ANSWERED NO, DESCRIBE I THE REASON IN DETAIL IN THE EVENT REPORT.  :

p B. PERSONNEL ERRORS '

1. WERE JOB ENVIRONMENT CONDITIONS SUCH AS LIGHTING, i VENTILATION, EXTREME TEMPERATURE OF P ICAL ACCESS TO THE TASK CONTRIBUTING FACTORS? YES O

] 2. WERE PROPER TOOLS AVAILABLE AND USED7 /NO 9 ,

3. WERE WRITTE 4PPROVED PROCEDURE AVAILABLE AND PROPERLY

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FOLLOWED7 YE No i

l 4. IF THE PROCEDURE WERE FOLLOWED, WAS PR DURE t

COMPLIANCE A CONTRIBUTORY CAUSE7 YES 0 i

5. WERE ADEQ NSTRUCTIONS GIVEN AND COMPREHENSION VERIFIED 7 NO

6. WERE THE PERSONNEL INVOLVED IN THE PROPE2 PHYSICAL l CONDITION 7 if0 3 7. DID THE PERSONNEL INVOLVED HAVE ERR 0NEOUSpIDEAS AND/OR CONCEPTS ABOUT THE SYSTEM INVOLVED 7 YE

8. DID THE PERSONNEL INVOLVED HAVE PREVIOUS RIENCE i

AND/OR TRAINING ON THE SYSTEM INVOLVED 7 YE NO 1

9.

DID THE PERSONNEL RECEIVE A BRIEFING QF THE EVOLUTION PRIOR TO STARTING 7 YES/NO g/f ragpf,,g /e 70 M*/ 75

10. a 45a s sso m WERE COMMUNICATIONS ADEQUATE FOR THE EVOLUTION 7 g/NO

11. WERE COMMUNICATIONS TESTED PRIOR TO STARTING 7 YES/NO Al# Abr -/fSWt' 4

1 1 ** Met

. - . . . . . - . ,-. . _ . - _ . - _ . . . . - . . . - - _ . . _ ~ . - .

MNE NO. Kgytagg paug so, VEGP 00057-C 5 37 of 37

. Sheet 10 of 10 DATA SHEET 1 Event Report No. 32, Report: Page g of h - i INVESTIGATION QUESTIONS (CONT'D)

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12. WAS SUPERVISION IN NT ADEQUATE FOR THE EVOLUTION i BEING CONDUCTED? ES NO l 4

13. WERE THE PERSONNEL THAT INITIATED OR ADVERSELY CONTRIBUTED TO THE EVENT QUALIFIED TO PERFOR&f-THEIR 1 ACTIVITIES PRIOR TO AND DURING THE EVENT? y SfNO

14. IF QUESTIONS 1, 4 OR 7 ARE ANSWERED YES, DESCRIBE IN

, DETAIL IN THE EVENT REPORT.

15. IF QUESTIONS 2, 3, 5, 6, 8, 9, 10, 11, 12 OR' 13 ARE I ANSWERED NO, DESCRIBE IN DETAIL IN THE EVENT REPORT.

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emoctou-a NO. REVISloN FAGE No.

VEGP 00057-C 5 26 of 37

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EVENT PERSONAL STATEMENT l 1. a.FOR THE PERIOD PRIOR TO, DURING, AND AFTER THE EVENT, SUMMARIZE THE SEQUENCE OF EVENTS THAT YOU OBSERVED, AND YOUR SPECIFIC ACTIONS TAKEN BASED ON INDICATIONS.

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b. List alarms that illuminated and/or were reset. .G4c4 cchcw

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v.u c r cmcue<t . u.om Acc & K.,s <c+r+ +c L.GF- J DID ANY AUTOMATIC SYSTEMS OR EQUIPMENT MALFUNCTION REQUIRE ANY OPERATOR INTERVENTION? (Describe)

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3. DID THIS EVENT REVEAL ANY PROCEDURAL INADEQUACIES?

(Describe)

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,. MioCEDUAE NO. KgylSION FAGE NO.

VECP 00057-C 5 27 of 37 k*

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Event Report No. , I Report: Page 17 of TE h-i 4 IF THIS EVENT OCCURRED AGAIN, WHAT WOULD YOU DIFFERENTLY? I i

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ARE THERE ANY LESSONS LEARNED FROM THIS EVENT THAT YOU-BELIEVE SHOULD BE INCLUDED IN TRAINING 7 (Describe) l bt i

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6. COMMENTS: ~

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FIGURE 2 (CONT'D.) EXAMPLE E

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, PROCEDURE NO. AgySloN PAGE NO.

, VEGP 00057-C 5 26 of 37 Event Report No.

Report: Page er'bc -6 v

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EVENT PERSONAL STATEMENT

1. a.FOR THE PERIOD PRIOR TO, DURING, AND AFTER THE EVENT, SUMMARIZE THE SEQUENCE OF EVENTS'THAT YOU OBSE"VED, AND YOUR SPECIFIC ACTIONS TAKEN BASED ON INDICATIONS.

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b. List alarms that illuminated and/Or were reset.

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2. DID ANY AUTOMATIC SYSTEMS OR EQUIPMENT MALFUNCTION REQUIRE ANY OPERATOR INTERVENTION? (Describe)

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3. DID THIS EVENT REVEAL ANY PROCEDURAL INADEQUACIES?

(Describe) ,

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VECP 00057-C 5 27 of 37 a .

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i Report: Page W-Tot --C 19 4 IF THIS EVENT OCCURRED AGAIN, WHAT WOULD YOU DIFFERENTLY?W""

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i I 5. ARE THERE ANY LESSONS LEARNED FR M THIS EVE:fT THAT YOU BELIEVE SHOULD BE INCLUDED IN TRAINING 7 (Describe) u L. - J / 4:s ,l p e I  :

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l 6. COMMENTS:  ;

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• 1 For reactor trips the personnel statement form in Procedure

1000 M may be used in lieu of this form.

FIGURE 2 (CONT'D.) EXAMPLE

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