ML20137Y094
| ML20137Y094 | |
| Person / Time | |
|---|---|
| Site: | Paducah Gaseous Diffusion Plant |
| Issue date: | 04/16/1997 |
| From: | Polston S UNITED STATES ENRICHMENT CORP. (USEC) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| GDP-97-1004, NUDOCS 9704220319 | |
| Download: ML20137Y094 (7) | |
Text
United States e
Ennchment Corpwation Paducah Site Office P O. Box 1410 Paducah. KY 42001 Tel. 502 441-5803 Tax 502 44l-5801 April 16,1997 l
United States Nuclear Re' ulatory Conunission SERIAL: GDP 97-1004 Attention: Document Control Desk Washington, DC 20555-001 Paducah Gaseous Diffusion Plant (PGDP) - Docket No. 70-7001 - Event Report ER-97-06 Pursuant to 10CFR 76.120(c)(2), Enclosure 1 is the required 30-day written Event Report covering ER-97-06. The event relates to a water flow alarm in the Central Control Facility (CCF) caused t,y a tool box rupturing a sprinkler system pipe. The Nuclear Regulatory Commission (NRC) was notified of the event on March 19, 1997. Enclosure 2 is a list of commitments made in the report.
Shculd you require further information on this subject, please contact Bill Sykes at (502) 441-6796.
- erely, 1
Steve Polston General Manager Paducah Gaseous Diffusion Plant SP:WES:JLil:mel Enclosures (2) cc: NRC Region III NRC Senior Resident Insp:ctor, PGDP
\\
g%N 220110 foA**!8SM E88&1 til!lilV3M4%
PDR u
4,
' United States Nuclear Regulatory Commission Page Two April 16,1997 Distribution Robert L. Woolley bec:
J. Adkins, USEC-HQ D. Allen, PORTS M. Boren S. Brawner J. Dietrich, LMUS-HQ L. Fink, PORTS R. Gaston, PORTS C. Hicks J. Labarraque B. Lantz, PORTS R. Lipfert, PORTS J. Miller, USEC-HQ J. Mize S. Penrod H. Pu ley A. Rebuck-Main, USEC-HQ S. Routh, USEC-HQ J. Thomas S. Scholl, PORTS B. Sykes R. Wells, USEC-HQ File: 97-890-129 0:\\ users \\nra\\pgdp\\97-06-er
6 Docket No. 70-7001 Page 1 of 4 i
EVENT REPORT ER-97-06 BACKGROUND The Paducah Gaseous Diffusion Plant (PGDP) fire protection systems and equipment are designed to detect, contain, and suppress fires. The major process buildings at PGDP (C-331;
-333; -337; -310; and -315) are constructed of unprotected steel frames, concrete floors, noncombustible exterior walls, and a built-up metal deck roof assembly. Fixed automatic fire suppression systems provide the means for the detection and control of fires at the plant. Each building is considered a single fire area; sprinkler coverage is provided, except for cell housings and surge drum rooms. There are no fire barriers between units / areas in the process buildings. Combustible loading is low, except for tube oil, and the fire hazards are limited to l
normal industrial activities. Emergency response is provided by the on-site Fire Services Group and Emergency Squad. The Plant has mutual aid agreements with other fire departments in the county.
As discussed in the SAR Accident Analysis (Sections 4.3.2.5.1 and 4.3.2.5.2), an unmitigated lube oil fire in the process tube pits, or on the cell floor, could cause failure of the structural steel, followed by localized collapse of the structure. This collapse could damage process piping allowing a release of UF. The sprinkler systems are designed to actuate in sufficient 6
time to prevent structural collapse and a potential release of UF.
6 DESCRIPTION OF EVENT i
Plant Maintenance is performing work in the C-335 process building in preparation for the Seisinic Upgrade Project. Included among the various tasks being performed is the relocation I
of conduit and light fixtures so the subcatractors involved in the Seismic Upgrade Project can l
perform their work without being hindered by obstructions.
l On March 19,1997, at approximately 12:40 p.m., a plant maintenance employee was moving l
a tool box on the cell floor of C-335 when a valve on sprinkler system No. 27, located at j
column number FF-21, was struck by the tool box. The impact resulted in a crack in the l
sprinkler system pipe at a pipe coupling approximately two feet above the inspector test valve 1
(ITV) causing a water leak.
U The resulting leak caused a water flow alarm on the fire alarm system located in the C-335 Central Control Facility (CCF). The Plant Shift Superintendent (PSS) initiated a response by Fire Services personnel who closed the system's post-indicating valve (PIV), isolating the l
1
. Docket No,' 70-7001 Page 2 of 4 system, and stopping the leak. The sprinkler system was declared inoperable at 12:55 p.m.
. Technical Safety Requirement (TSR) 2.4.4.5, " Fire Protection System - Building Sprinkler System," Limiting Conditions For Operation (LCO) requires the sprinkler systems in the process buildings to be operable. The PSS directed appropriate LCO actions which included the performing of a fire watch of the affected area to be initiated within two hours and conducted every hour thereafter, and confirmed that at least one high pressure fire water (HPFW) hydrant adjacent to C-335 is operable within four hours. The first fire patrol was completed at 1:30 p.m., and subsequent fire patrols were being performed on a continuing basis every hour. The HPFW hydrant was confirmed operable at 1:55 p.m.
An investigation team was established to determine root cause and corrective actions to preclude recurrence. The team focused on two areas: (1) determining how the tool box caused the accident; (2) determining the cause for the employee not successfully reacting to preclude impact with the sprinkler pipe.
The tool box is described as a "Greenlee Gang Pox," and is utilized to store and transport numerous tools that may be required by maintenance personnel in the performance of their assigned tasks. The tool box is mobile with rubber-tired casters located in the front and rear with the front casters only being capable of moving forward and backward, but the rear casters are capable of swiveling 360 degrees. The tool box is 66 inches long, 33 inches wide, and 56 inches high. The empty weight of the tool box is 351 pounds. The interior of the tool box contains 50 cubic feet of storage space, and when tools are placed in the box the estimated gross weight is 1000 pounds.
On the date of the incident, the maintenance work crews moved to various areas of the building to perform their work. Normally, a motorized vehicle, such as a fork lift, transports the tool box where needed; however, a fork lift was not available. An employee was pushing the tool box toward another location which required him to negotiate a turn to the right, at which time the rear of the tool box began to move sharply to the left striking the sprinkler system valve, which caused a water leak at the coupling joint. The employee made an attempt to stop the movement of the tool box toward the sprinkler system valve. The attempt to stop the movement was not successful because of the weight of the tool box. The employee, upon noticing an unknown leaking substance, immediately implemented the plant's "See And Flee" policy, and departed the area. He reported the incident to a Cascade Maintenance Supervisor who initiated response procedures.
There are no indications that the employee was moving the equipment in an unsafe manner. It appears that while making the right turn, the rear swivel casters caused the tool box to over-correct to the left, causing the tool box to strike the valve.
s Docket No. 70-7001 Page 3 of 4 J
l 1
On March 24,1997, the pipe on sprinkler system No. 27, in C-335 was repaired and returned i
to operation.
A review of pertinent records was conducted to determine whether there were indications of an adverse trend involving damage to, and subsequent removal from service, of safety systems / components as a result accidents inside the process buildings. The review focused on accidents caused by tool boxes, motorized equipment such as fork-lifts, and bicycles. The results of the review indicates that there are not any adverse trends. Therefore, the accident that led to this event is considered an isolated incident.
CAUSES OF EVENT A. Direct Cause The direct cause of the damage to the sprinkler pipe was failure to maintain control of a tool box weighing approximately 1000 pounds while attempting to negotiate a turn.
B. Root Cause The root cause of the damage to the sprinkler pipe was that the employee had not been trained to anticipate the possibility that equipment may not respond as expected or intended.
C. Contributing Cause None CORRECTIVE ACTIONS A. Completed Corrective Actions None B. Planned Corrective Actions
- 1. On March 27,1997, the Maintenance Organization Manager directed that a crew briefm' g/ required reading be conducted emphasizing the need to exercise extra caution when moving heavy equipment and loads in the same areas where process equipment is
, located. By May 9,1997, the crew briefing / required reading will be completed.
i l
. Docket No. 70-7001 i
Page 4 of 4 1
Deficiency notices will be issued to all Maintenance craft employees who have not completed the training by the date, above.
i 3
2.
By May 16,1997, Maintenance personnel will attend, and complete, for.nal " Conduct Of Training" that encompasses the STAR (Stop, Think, Act, Review) principle. The i
STAR principle is intended to make employees aware of their work environment to i
preclude accidents similar to the one that led to this event. Deficiency notices will be issued to all Maintenance craft employees who have not completed the training by the date, above.
3.
By October 17,1997, the Maintenance Organization Manager will complete an end-5 point assessment to determine the effectiveness of the corrective action. The results of j
the assessment will be documented and made a matter of record.
1 4
T FSSONS I.FARNED
.l 1
t l
When operatmg equipment in the vicinity of safety systems, or safety system components, j
extreme caution must be exercised to assure that the systems are not inadvertently damaged.
EXTENT OF EXPOSURE OF INDIVIDUALS TO RADIATION OR TO RADIOACTIVE MATERIAT S i
None.
i
4
~
. Docket No. 70-7001 Page1of1 1
Event Report ER-97-06 j
List Of Commitments
- 1. On March 27,1997, the Maintenance Organization Manager directed that a crew briefing / required reading be conducted emphasizing the need to exercise extra caution when moving heavy equipment and Lads in the same areas where process equipment is i
located. By May 9,1997, the crew triefm' g/ required reading will be completed.
Deficiency notices will be issued to all Maintenance craft employees who have not p
j completed the training by the date, abt vc
- 2. By May 16,1997, Maintenance personnel will attend, and complete, formal " Conduct Of Training" that encompasses the STAR (Stop, Think, Act, Review) principle. The STAR principle is intended to make employees aware of their work environment to preclude accidents similar to the one that led to this event. Deficiency notices will be issued to all Maintenance craft employees who have not completed the training by the date, above.
- 3. By October 17,1997, the Maintenance Organization Manager will complete an end-point assessment to determine the effectiveness of the corrective action. The results of the assessment will be documented and made a matter of record.
L
.