ML20153C818
| ML20153C818 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 10/15/1987 |
| From: | WOLF CREEK NUCLEAR OPERATING CORP. |
| To: | |
| Shared Package | |
| ML20153C561 | List: |
| References | |
| FOIA-88-68 MPE-E009Q-01, MPE-E9Q-1, NUDOCS 8805060325 | |
| Download: ML20153C818 (106) | |
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. f '.$.d 8WITCHGEAR INSPECTION AND TESTING 4
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<? ~7 IfiDEPENDEW REVIEW,[q..:. 3'2; Q, dC;. '. -
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DATE
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PLANT MANAG$R'hPPROYAL (Revision 0 only)
/0 /[ f QUALITY ENGINEERING (As required per 6.7.1)
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8805060325 880426 PDR FOIA LYKINS88-68 PDR h.-3
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.x.y 1.1 This procedure describes the inspection, testing, and i.D maintenance to be performed -on.13.8 KV.and 4 16 KV c:hMi6MSp'.i
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Switchgear.,y.flg g G.%.2.{,4 4 {;.y.((!h!
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APPLICABILITY. Vff F, 2.;;(...q;:p.j, r,Wh,&;
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'gcs, 2.1 Jis. applicable'gt
- .'. Switchgear t.J PA01,'3 PA02,. PA0 3,,o,.
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.:.PA04,; PA05, PA06, PB03, y y ;;
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3.0 NOTES AND PRECAUTIONS
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%C 31 Copies of the attachment.' sign-off sheets shall be ma~de $N M., WC-and attached to this procedure for each cubicle and %k s IE
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potential transformer maintenance ^ performed.Ff:P - Jd;. db 5 I#
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Circuit breakers that have ~been remo..~.
ved from'their hy cubicles should be covered and protected, if left out %g g..
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of the switchgear for an extended period of time.d;.gg %.
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e.g.
- 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />.
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5%g.pt Notify QC ' prior to commencing ~q-.d;dyy{*
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33 work :on.., safety-related.,g. ?.g' p;
marked N/A in the QC sign-off
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3.4 There may be high voltage potential present in the W .. -
.switchgear and the tie breaker (primary; disconnecting ;j,.Qy Q
gce devices even through the bus is de-energized and
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grounded.
Areas where high voltagi may_be present '.c "NND
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S shall be identified prior to' operationssupport,'toraise_~&commencingwork.*'h
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.andlower,breakersetc.,'#';'9p.h,@
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is not required once the bus O ONW.
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..e 3.6 If a second or third shift continue with the work, they '.N' ' k J:1 will need to sign off on the "Second Shift" lines on the Sign-Off Sheets.
s, 3.7 No work shall be performed on the equipment until the
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voltage checks have been completed and the personnel are confident that they can safely complete the work
'..' N instructions.
,t, MPE E0090-01 ag of 15 U.
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'4. 0 TEST EQUIPMENT,_ PARTS AND MATERIALS, REFERENCES ANDL'l,
ATTACUMENTS,j.s,.
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1..If,.any.._; equivalent. equipment is used, provide @ff
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NOTE:
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-justification in the Comment Section of the ?*kf'.r
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- Ground, cables..and. operations ground disk
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4.3 References And Attachments
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4.3.1 PA Bus - Vendor Manual E-009-223
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". 6,.:.. A 'c 4.3.2 PB Bus
. Vendor Manual E-009-241
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4.3.3 NB Bus - Vendor Manual E-009-242 0
4.3.4 SL-1, SL-2, SL-3, SL-4 Vendor Manua1 A-3801
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4.3.5 SL-ll, SL-31, SL-41 Vendor Manual A-3804 U
4.3.6 Attachment " A '.' - Swgr Bus Sign-off Sheet MPE E0090-01
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.~4.3.7 Attachment "B"
Swgr Cubicle Sign-off Sheet
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3P, Attachment""C" - Potential Transformer Sign-off Sheet
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4.3.8 C~>4.39
.:e.%.'.. v.Q.::.. a)... i-.u... =.c...:':. m,f.m G Attachment ".D"ce' Restoration Sign-of f Sheet @@9a..)y.r,-a 7 HW.3i
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." - PREREQUISITES 9
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' Isolate and tag cut equipment iMf.
.J y 1 station clearance order procedure ADM 02-100..
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' Switchgearf breakers are racked down- (into the r...
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O ' 5. 3 Prerequisites complete.
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,y f;', WORK PERFORMANCE INSTRUCTIONS
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m Recheck to make sure all the supply breakers to. 3q + g,
NOTE:
voltagesupplybreakerandspaceheaterbreaker,".y
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.the'switchgear, tie breaker (if used), high 9.ihd
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-hs C U.i.@h.,. are OPEN.
High voltage breakers should be in 4gfW.s'%;e:
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their racked down position.
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6.1
.. Check..theelectrical'drawingsandidentifyanyarea(s')'),
c.
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~ which willlhave high voltage potential present(even i.ff "3-
- s' when the Bus is grounded.
List the areas on the kt Sign-off Sheet.-
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/,, L of a safety hazard (e.g.,
- portion of equipment
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energized) U/A that step and note why it could
,not be done..
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6.2 Grounding Switchgear Bus
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6.2.1 Determine which cubicle will be used to ground the high
- +
voltage bus, and the size (Amp rating) of the breaker it is designed to accept.
(1200, 2000, or 3000 Amp).
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.r 6.2.2 Remove the breaker from the selected cubicle (if applicable).
MPE E0090-01 l
Rev. 1 E,%.S3!!.a \\.a Page 3 of 15 hd 1
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6.2.3 Determine the correct ground test device to go with that cubicle.
If necessary, move the high voltage stabs of.
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the ground test device to the bus position..On 4.16 KV
. ground test. device.s,. an. adapt,or needs to be placed on
.. d'7 4k',k the high voltage stabs for the' 2000 Amp cubicles.
-(The adaptors are located in the Electric Shop "Special
.s
,a J-Tools" area).
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-E,a fresh fcoat[.sround cables ' installed; I and that" there "l..
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of contact gre'ase on the high voltage,and'.?
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-Roll--the ' ground test device into the cubicle. Raise 4fdQ.
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- the ground ' test device to the connected position, and MN}
..-i while raising observe the shutter opening, the H.V. j.3,.-jf yE stabs entering the tubes, the ground stab properly.J.@, '
. mating', and the ground test device coming to rest close,.l i'
fw to the m'echanical."stops. ', !.
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test device, check phase to phase and phase to ground _
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und cables..,p( '..t,&;j,.:Yh
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6.2.7 If.no voltage'is present,,, install the gro,.
9 (with operations ground. disk) on the ground test fl
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device.
(Second and third shift to re-verify the k.
b ground cable is still installed).
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disconnected position.
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6.2.9 Switch'geah.
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6.3 Cubicle Maintenance And Testing
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6.3.1 Roll the breaker'o!,
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connected position.
t.' 7 '
.4
. =;V
,s 6.3.3 Raise the breaker elevating rack and observe the operation of the shutter mechanism.
The shutter should operate freely and open far enough to expose the ceramic on the stationary rossettes.
- w*****************
- CAUTION:
If voltage is identified, STOP work and
- immediately notif
- -****************y your supervisor.
MPE E0090-01 Rev. 1 Page 4 of 15 y
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6.3.4 Using high voltage gloves and tester, check the rossettes to ensure that there is no voltage present.
o C-Check phase to phase, and phase to ground on all six.
T
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6.3.5..
If no voltage is identified in Step 6.3.4, discharge,e:
,: %.g. '
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b o t h l i n e a n d l o a d s i d e r o s s e t t e s. --
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- .
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p;'6 '. 3. 6 J.s e'l.. Lower the breaker elevating:.r....e,
.:. m.s. ;. rack andfagain observe?the%.y>
j "s..q 3 +
.,... r
. w.W.:' W?g-?vT. operation of. ;the'.7 ;i,Wlb$c'shu tte r.. ' M11QM.
re
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d'&M"'Q P3 M,7g, ' ~ Carefully remov,e ' bolte S'
- 6AW M?W d -
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'-V T els, front and re %r,Y$!.
,., j:. ;:.- 6. 3.
I a
as a t
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only.
Do not enter a potential transformer y _, e 3 5'*5-g
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compartment. w.*Y MM & ",.sa:+1W% i>.6.. s.., :sk:D *BG.kW
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- CAUTION: (If voltage is identified, STOP work and.'* d@
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inanediately notify your su
- pervisor.'
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6.3.8 Check the cables in the back of the cubicle (using high
.pff.
voltage gloves and a detect or flow lamp tester) for.a
.xf/1' the presence of voltage.
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6.3.9 Put the trip, close, and elevating fuses in the
. JM.. 4..
g'g,;
disconnected position.
. c.,3..
.,, -,.;y ?.
-.L,1
(..
.q
(
6.3.10 Clean any dust,' dirt,' or other foreign material from 4
' 0CM the switchgear cubicle.
Ensure the insulators are clean and no cracks are visible.. Check for any signs of overheating.
~
. + M spf"J'ki'5.,.-e M..<M' M #2d 6 ".@"
(,9
'w NOTE:
Use caution since some equip'nent may still be [. '
n -physically hot.
e.g.,
-- space heaters.
,9 u :..
OC to monitc7 FAY;w'sitre that the insulators are free of
.;iN '
.e.
- 5.-
6.3.10.1 n
cracks or other damage and that exposed buswork and
.p-connections show no visible signs of deterioration or
^ Of.
overheating.- '..g '
4 3%,
.-g,,.
6.3.11 Clean and lubricate the breaker elevating mechanism M
jacks screws and gears.
6.3 12 Check to ensure that the electrical control circuit connections on the door and in the cubicle are tight.
.,u..
i MPE E0090-01 Rev. 1 Page 5 of 15
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6.3.13 Check the contacts on handswitches (having exposed contacts or removable covers) and relays in the cubicle
- C.,,,'
for signs of excessive arcing or pitting.
If
.j; necessary, clean the contacts,with a burnishing tool.,
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.,.' 4 6.3.14 Remove the elgvating fuses and reinstall them in the
-,i(;,
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breaker'elevatin V > ~ k and observe the ' g
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f h.qMp{dU..operatefreelyand,open.farenoughto, expos F
.Th operation of the shutter mechanism.
The shutter'should i r
(f
,;;. d,9C ' ceramic on'.the, stationary rossettes."..~* -+F
?
4-4.Tg
- " P'6.3.16 Check again to ensure the rossettes are disc.harged,M. 9 Q~~. '.i.. _
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andcleantheinsulatorandhighvoltageconnection.Mf',@ QJg I
in each tube.
Check the insulators for cracks and the
n.E'.i
'D F,7 NI rossettes'for ' damaged fingers.
~ '#
,...~
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6.3.16.1 QC toinonitor to ensure that the insulators are free'of $, 2.jdb
^. *.
cracks or otier damage.
.. b.
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. -a,;
6.3.17 Lower the breaker elevating rack and again observe'the lj j.,.
j operation of the shutter.
d
.m.
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". 6.3.18 Put the trip, close, and elevrting fuses in the
, c..
.;r
~7
' '/.7 disconnected position.
.','-J.
- n '..
- i-6.3.19 Notify the Metering and Relay Group that the cubicle C
maintenance is complete and that they can perform their _
e functional checks on the relay circuits.
6.3.20 Reinstall the panels removed in Step 6.3.7.
f
.,3
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6.3.21 Ensure that there is a light, fresh coat of contact lN'; ~ i.
f' F grease on the high voltage, ground stabs, and secondary.
fingers on the breaker.
,.: *:., :..,.. g.
_..;~,',.--. :..,
. c.
.w 6.3.22 Carefully roll the breaker back into.the cubicle.
6.3.23 Cubicle maintenance, adjustments, and testing are
~
complete.
6.4 Potential Transformer Maintenance 6.4.1 Roll out the potential transformer drawer and make sure the primary connections on the drawer make contact with the grounding fingers.
NOTE:
Use caution when performing Step 6.4.2.
High voltage potential may be present.
MPE E0090-01 Rev. 1
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6.4 2 Remove bolted panels as necessary to obtain access to i
the stationary portion of the high voltage disconnects..
C* '...
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- CAUTION:. If voltage is idehtified, STOP work and *.,...
.3
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- y notify your supervisor.
f.e inanediatel
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voltage gloves and testor, check,th.f.6,... p<xp c' tr.~.
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stationary; disconnects;.forhighvoltagepotential.:dI[g,[,Mi{ My
$I$5.n-Ql,'N.;.d.t6.,@.4W.'s$$6&~:.c.Ifnovoltagenisidentifiedin' S
$@5.
[.6. 4'. 4 dh.N e,i'v.% dm v--
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w TNT.43'ri liW high voltage cables.-
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6.4 5 Ensure that the potential transformer compartment
.QCM
['?. -
insulators', drawer contacts, and fuse tubes are clean 9.)[^, fj; ~
W 'J-Y and free of contaminates.
Insulators should be cleaned r ~-
M h...'i@ly by use of stoddard solvent or equivalent.
Clean fuse ~L G;. f.(-:
clips and drawer contacts with CRC contact cleaner or,.,G' :4'... y' J'
.T:,
~
equiva1ent.
- a@;~,
Q.~
w:;;
.. p 6.4.5.1 QC to monitor to ensure that the insulators are free of
.3
[}"
cracks or other damage.
.d.
%7 n
.7 h..6.4.6' check the electrical connections to ensure that they * '.' - i'QCM are tight, and the fuse clips for proper tension.
et.
check crimped connections for signs of overheating.
p.
C 6.4.6.1 QC to monitor to ensure that the electrical connections
^'
~.
show no visible signs of overheating or deterioration.
6.4.7 Put a light film of contact grease on the high voltpge,
- ciG.i
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ground, and secondary fingers.
ep.
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6.4.8 Lubricate the drawer slides with*GE-D50H15 grease... 'w g.. " 1 '"'M..
m-ga x:
w.
.6.4 9 CLOSE the potential't'ansformer drawer, observing th b N.h:
r operation of both the high voltage and secondary disconnects.
N
.h 6.4.10 OPEN the potential transformer drawer and inspect the wipe marks on the high voltage and ground disconnects.
If necessary, adjust the spring portion to correct the constact wipe.
6.4.11 Manually check the secondary disconnects for freedom of movement and spring tension.
6.4.12 Reinstall panels removed in Step 6.4 2.
MPE E0090-01 Rev. 1 p,
g-Page 7 of 15 6 1 1a j;.;A w
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6.4.13 Perform a Megger Test on the potential transformer OCM per MGE EOOP-05.
Record this reading on the Sign-Off C
Sheet.
.u.-
r,.-
.. y..... g.,..,.
6.4.13.1 OC to monitor Megger Test per*MGE EOOP-05 and document ~
~
acceptance on.this. Sign-Off. Sheet.
':.t
& N 6.4.14' Potentia 1' transformer maintenance and testing is
. NS " * ".. l '
S.
N'?.'GGnN
- h(_~.?!h];f;*l.omplete.S'iL W @.n d M @3'#Ys c
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+
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[
gyy, '. e. C ". n ' NOTE:.All work to be performed under Steps 6.3 and 6.'4.j;.i; g'
should be completed on all available cubicles,o.,,.
..i.l y
-, ;NJ y,P,";,. q'@
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JYl'-
before the bus meggering is performed. wt-dvf!W;?
6.5.1 OPEN all potential transformer drawers to the grounded f :.b','
position.
djr},,j' ( g..
., :..,y..Q i1f NOTE:_ Operations should be notified when grounds are, * * ' '.,4 removed.
r1
,r
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+ s.
6.5.2 Remove the ground cables installed on the ground test ~
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device.
,;;g;,.
,, j..
6.5 3 Megger the switchgear per MGE EOOP-05, and record OCM readings and megger voltage used on this Sign-Off
.]..
Sheet.
~;
.e 6.5 3.1 OC to monitor Megger Test per MGE EOOP-05 and document acceptar.ce on this Sign-Off Sheet.
6.5.4
' Install t.he elevating fuses in the connected position'
. :j.$
and lower the ground test device.
,~,9 R
y 6.5.5 Remove tna ground test device from the cubicle and put 31 9-l '
thi e1%ating fuses in the disconnected position.
16 ' ~
6.5.6 CLOSE all potential transformer drawers.
6.5.7 Switchgear. bus meggering complete.
6.6 Restoration 6.6.1 Check to ensure the ground cables have been removed.
6.6.2 Energize the space heater circuit breaker and check the space heaters to ensure they are operable.
l MPE E0090-01 Rev. 1 Page 8 of 15 f, h. f b
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4 6.6.2 Check the breaker elevating mechanisms are in the
.s:
- 4. n -
lowered position, and roll any remaining breakers into.
./
their respective cubicles.
$.s C'
"6.6.4
.g v:
Place the trip, ciose, and el'evating fus'es for each "-i.
g.[
.r cubicle in the connected position.
.j ed.
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ac
,. : v..
,..N#4,/ONk t.s.M'A s:.n -
rd t-I.
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' Restoratio..n complete.
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MPE E0090-01 Rev. 1 Page 9 of 15
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ATrAGMENT "A" WR to.
('
SW3R. BUS SIGt N FF SHEEP j
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6 %'.
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.7 TEST EDUIPMENT USED
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DESCRIPPION W.C. NO.
CAL. DUE MTE DESCRIPPION W.C. No. ~
CAL. DUE DATE
!!?.* DESCRIPPION W.C. NO.
. DESCRIPTION W.C. NO.
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_q 5.3 PREREQUISITES CDMPLETE
/
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. INITIAL.;y
/ DATE l
6.1 AREAS WHERE HIGH VOLTME EUTENTIAL IS STILL PRESENT WITH BUS GROUNDED'
, :.s n,s -.
4 C
/
INrrIAL MTE SB::OND SHIFT MIRD SHIFr INrrIAL/DATE INrrIAL/DATE 6.2.3 CDRRECT GRWND TESP DEVICE AfD ADAPIORS
/
INITIAL
/ DATE l
6.2.6 BUS GEDTD FOR HIGH VOLTME PCfrENTIAL
/
INITIAL
/ DATE 6.2.7 GM CABLE INSrAurn
/
INITIAL
/ DATE
/
INITIAL DATE VERIFIED SEIDND SHIFT VERIFIED MIRD SHIFT INITIAL /DATE INITIAL /DATE 6.2.9 SWIIQUEAR GPCUNDDX3 CDMPIErE
/
INITIAL
/ DATE CDEENTS:
MPE E0090-01 f
Rev. 1
(
Page 10 of 15 k
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CI2 EIDER 'IBE ICUIPMENT ENEIGIZED INrIL M UAVE PEP.SCNAI1X PBOVEN OIBERWISE CJBICLE BO.
ATTACEMENr "B" WR No.
SWGR. CJBICLE SIGN-OFF SHEETF al -
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.pr 6.3.3 SEUITER OPERATES FREELY a-
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CHECKED AND VERIFIED 10 VOLTAGE IS PRESENr "
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7,.;.. - INITIAL /DATE % s-VERIFIED BY 'M(F 7
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.. 3.g 6.3.5 LINE AND IDAD BOSSETTES ARE DISCHARGED
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INITIAL CHECKED AND. VERIFIED 10 VOLTAGE IS PRESENT
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INITIAL /DATE
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INITIAL /DATE
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e LS5S'i 6.3.10 CJBICLE IS CLEAN AND INSUIA'IORS CHECKED
' ~~
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INITIAL
/ DATE,.
M... a. -
6 QC FONrIOR INSUIA'IORS FREE OF CRAQ<S AND NO C
.3.10.1 O
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-J SIGNS OF OVERHEATHE OC INITIAL
/ DATE 6.3.11 EIEVATHE MECEAtTISM WBRICATED
/
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INITIAL
/ DATE
/ \\ *,
4 6.3.12 ELECTRICAL CJNNECTIOtE CHECKED
/
INITIAL
/ DATE 6.3.13 SWIIUI AND REIAY CONTACTS CHECKED
/
INrrIAL
/ DATE 6.3.16 INSULA'IORS AND EOSSETITES CHD:XED
/
INITIAL
/ D, ATE 6.3.16.1 QC FONTIOR INSUIA'IORS AfD POSSETITES FREE OF CRAC<S AND OIIIER DNiAGE QC
/
INITIAL
/ DATE MPE E0090-01 Rev. 1 Page 11 of 15
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CD3 SIDER 'IEE EQUIPENT ENERGT'Un I.NTIL YOU HAVE PERSCNALIX PROVEN crERRWISE C
QJBICLE NO.
ATTAQiMENT "B" WR No.
SWGR. QJBICLE SIGN-OFF SHEEP f[
(Continued)
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ELEVATING EUSES RDDVED
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PANELS RE-INSTALLED
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6.3.23 CJBICLE MAINTENANCE CDMPIZIE
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MPE E0090-01 Rev. 1 Page 12 of 15 ran Ilf h[
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CINSIDER 'IB8 EQUIPMENT ENERGT'7Pn LNTIL YOU HAVE PERSGAILY PIOVEN OIEERWISE C.
P.T. No.
ATF1CIMENT "C" WR No.
POTENTIAL TRANSOENER SIGN-OFF SHET w.
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WOLF CREEK GENERATING STATION
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REFUELING OUTAGE il STATUS MEETING OCTOBER 21,1987 i
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' NUCLEAR OPERATING CORPORATION i
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L-ATTENDEES BART WITHERS PRESIDENT AND CEO FORREST RHODES VICE PRESIDENT NUCLEAR OPERATIONS DICK GRANT VICE PRESIDENT QUALITY l
GARY BOYER PLANT MANAGER MIKE ESTES SUPERINTENDENT OF OPERATIONS OTTO MAYNARD MANAGER LICENSING e
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WOLF CREEK GENERATING STATION 4
i REFUELING OUTAGE 11 STATUS MEETING 3j OCTOBER 21.,1987 i
AGENDA 1.
INTf ODUCTION ll.
DESCRIPTION OF EVENTS Ill.
IMMEDIATE ACTIONS TAKEN i
IV.
EVALUATION RESULTS V.
CONCLUSIONS O
d e
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s Memo to Supervisocc:
l Pre-Job Briefing Pre-Job Briefings have always been a good idea and most Jobs used it as a tool for a better performance. They were not a requirement placed upon the work force by management. The good practice will now S?
required. A Pre-Job Briefing for all work at Wolf Creek will take place as a specific function for all work activities, in or out of an outage.
It will take place between the worker (s) and the lead or supervisor, prior to cocmencing work.
It will be as short or long as the e
complexitles of the Job require, but a few speelfic areas will be covered in each briefing. These will include:
)
- 1. Safety precautions for the Job including the clearance order.
- 2. The actual procedures to be used will be reviewed.
- 3. A general discussion of the Job complex!tlea and potential problems.
- 4. This function, a pre-Job briefing. will repeat prior to each shif t starting work in the field if a Job is an on-going one.
This concept must become a way of life at Nolf Creek.
It is an appropriate level of control in our business.
Forre-t T. Rhodes
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Vice President t
Nuclear Operations 1
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INTEROFFICE CO R RESPON DE NC E NUCLEAR OPOWWG CORPo% DON
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Operations Personnel OP 87-173 FRCri:
J. L. Houghton DATE:
lbverber 21, 1987 i
SUa71rT:
Use of Procedures i
j Procedures are to be used per AI24 02 -021 for all operations of systems.
Exanples of situations where procedures 'nust be used are : 1) deenergizing ard energizing electrical busses, 2) shutting doen a system to hang a Clearance Order or 3) restoring frcm a Clearance Order to fill, vent, ard return to service. Effective innediately, the Work Pequest and Clearance Ortier procedures are ro longer adequato, by thenselves, to deenergize, energize, drain, or fill and vent system for maintenance.
As a matter of gced operating practice, a qualified watchstander should walkdcwn the system that is being removed frcm a Clearance Order boundary, prior to rencving the asso:iated Clearance Order, to assure that all the work-has been ccxrpleted.
t It is inportant that each one of us clearly understands the ifrportance of using precedures correctly ard that we do the jcb that is expected of us.
Procedures are docunentation that we have done our job correctly ard satisfies the requirements of Fog. Guide 1.33.
Your oco,teration is necessary.
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i News Release ApprovedbyPhone 10:05 p. a.
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A notification of unusual event was declared at Wolf Creek Generating j
., Station at 8:37 tonight following injury to three workers. The notice of unusual event was cancelled at 9!11 p. m.
The accident involved injury to three workers in an enclosed switchgear area.
3
' faey were taken to a local hospital.
Circu= stances of the accident are under investigation.
Information on the Work Willnotbereleaseduntilfamilieshave beennotified.
NolfCreekStationhasbeenshutdownsinceSeptember27foryearlyfuel re-loading. The accident did not involve the reactor. There was never any threat tothepublic. There was no release of. radioactive materials.and none.vas. _ _ _..
threatened.
The plant's energency idcas plan was activated. A notification of unusual event is the.least serious of four emergency classifications for nuclear generating
(
. stations. set by the Nt. e ar P.egula tory. Commis sion...........................
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Update of this story appro ed by phone 11:10 p. m.
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- We are report &., k one h'm fatality, a.ontract worker who W died following an electric burn.
- Two WCNOC employees were taken to the hospital for observation, and have been senthome.
They did not receive electrical burns. Tney were under observation for
, trana shock.
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Special _ Report to WCNOC Employees U_nusual Event, Fatality at Wolf Creek A Notification of Unusual Eveat was in force at Wolf Creek Station Wednesday evening from 8:37 p.m. to 9: 11 p.m.
A contract employee working on the NB02 Safeguards bus in the control building apparently came in contact with a potential transformer and
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received an electrical burn, lhe worker was taken to Coffey County hospital where he was pronounced dead. Name of the worker is being withheld pending notification of next of i
kin.
Two WCNOC employees were also taken to Coffey County hospital for observation, and were later released.
l At no time was there any threat to public health and safety. Work on l
the NB02 bus was suspended following the accident.
Equipment damage appears to be limited to *,he potential transformer. Further investigation into the accident is underway.
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b.kJ. d52b:, '. e.iii. h::~E* 4. ;a:.k.C..l..:. c. L.:O~nd. LT. 2.% : FMTu.i J. l i i i i Rsportable Event nu1ber 10331. 5 Facility : WOLF CREEK Date Notified : 10/14/87 Unit : 1 Time Notified : 21:45 t i Region : 4 Date of Event : 10/14/87 VGndor : WEST Time of Event : 21:42 ~ Operations Officer : MACKINNON Classification : Unusual Event NRC Notified By : M PETERSON Category 1 : Rad Release : No Category 2 : Cause : Unknown Category 3 : Component : Category 4 : l f EVENT DESCRIPTION : RTR IS IN MODE 6. TRAIN "B" 4160V WAS OUT OF SERVICE FOR MAINTENANCE. TRAIN
- A" WAS SUPPLING POWER TO RHR SYSTEM. ELECTRICAN WAS GOING IN FOR SWITCHGEAR CLEANING FOR TRAIN "B".
PLANT HAD LEFT THE TRAIN "B" TRANSFORMER ENERGIZED AS ALTERNATE POWIR SUPPLY FOR TRAIN "A". THE ELECTRICAN GOT INTO THE POTENTIAL TRANSFORMER AND HE RECEIVED 4160 VOLTS TO THE BODY. SMOKE WAS SEEN COMING FROM HIM DUE TO LARGE VOLTAGE SURGE THROUGH HIM. THE HALON SYSTEM i INITIATED. IN ORDER TO RIMOVE THE ELECTRICAN THEY HAD TO DEENERGIZE TRAIN aA" 4160 VOLT. WHEN TRAIN "A" WAS 'JEENERGIZED THE EDG "A" STARTED UP AND SEQUENCED LOADS ONTO ITSELF. SINCE THE EDG WAS SUPPLYING POWER THEY ALSO HAD TO MANUALLY DEENERGIZE EDG "A". WHEN EDG "A" WAS DEENERGIZED THEY LOST TRAIN "A" RER WHICH WAS THEIR ONLY OPERABLE RHR SYSTEM SINCE TRAIN "B" WAS DEENERGIZED. AFTER REMOVING THE ELECTRICAN THEY REENERGIZED TRAIN "A" AND HAD RHR TRAIN "A" BACK ON LINE. THE ELEC'TRICAN WAS TAKEN TO THE HOSPITAL. RTR CORE DID NOT HEAT UP SINCE MOST OF TdE FUEL HAS ALREADY BEIN REPLACED / REMOVED. RI WAS INFORMED BY THE LICENSEE. A4 30 (HUNNICUTT), IO ( PARTLOW), FEMA (WILLIAMS ) NOTIFIED.*** UPDATE 2215EDT*** UW'iUAL TERMINATED AT 2211EDT. RI WILL BE INFORMED BY THE LICENSEE. R 100 (HUNNICUTT), EO ( PARTLOW), FEMA ( AUSTIN) AND PAO (FOUCHARD) NOTIFIED.
- UPDATE 2340EDT*** ELECTRICAN DIED. RI WILL BE INFORMED BY THE LICENSEE.
R4DO(HUNNICUTT),EO(PARTLOW) NOTIFIED. l ~ \\ i D -S Fv4 u
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KG7-49, Rev. $/87 FL3 0 C? 37-34 WCNCC Dr.te US-19-87 PACG9NP% TIC DEFICIlXY REIORT _ Pro 9 1 of 1 I /, P A. Deficiency
Description:
B. Reportcd Ey D/C3 87-10_3 Date:__10/19/_87 j. R Phone: 2282 O 3 SECTIOi u on October 14(ifnent in the NB02 switchgear rcca. 1987, at 2022 an electrician c a e in contact with j I L energized equ 'Ihis reculted in a y E fatality. J M C. PHgramnatic RequitNment: i] I Personnel safety. ) D E N 3 E D. Initiate Cctrcctive Actica?: t:0 W (E:tplain 13clow) Ye3 p v A Identify Ibot Cause ard Corrective Acticnc necessary to prevent SECTICi L rneurren m. II U E. Irdividual ResI:ensible for Corrective Actica: M D Flch 7 A T P. Potential.ly Reportable: No [ Yec Q (Irplczent !CD III.17.0) I Itaf. D/c3 87-103 O G. Corrective Action Caspletion Datos.30/ 23/ 07 N j P II. Ictediate Corrective Actictr3 Taken: n o Sco Attached B L n-te Cenleted: 10 /15 /T7 'l C I. Rect Ccusc(s): ~ 11 Sea Attached Sa7?IC{ n III E J. Corrective tw:tions 'Inken to Pccvent i' currc.w: c S O See Attcched g U 04.e re nlovtb 'O /?? /37 e T _K. F.sedial Corrective Acticas Taken I' O Sco Attached D D ho Cr:p10ted: "f;f / !V L. All Corrective Actions Aru Verifcd cc Accc;tt_ic YesgEoh(E;;71&; sr.ccICu a IV I i F M. Individual h?x) Verified Corrective Actic=: W 6..__ _6U_Q_ Y f.I b*/I( 188 Ulf luitJI litUlt2p.L JtyptVVill. v-V - UdO 8 U)3/jlc1 ) 0 NA.1 It.N 5 U. 111!:12Pictit153: V U H R
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,st:0t 98/!2/2I Ia3 M33d3.r10M WOB.i ,(.....- 1 .4 EVET C2SCRIPTICN2 thirirx] the early evening chift on October 13,~1987, the Ehift Supervicor was making out the clearance order to tag out the 1G02 bus for cwitchgccr inspection and testing which was scheduled to be parforced the next &y. p We question came up if they stould tag out the tb.2 ESF trcncfor=2r which 1 is the normal feed to 1G02 bus. We Shift Supervisor called one of the Electrical Supervisors and asked hira if he had any prob 1cu 1eming the th2 CSF transformer (XND02) energized in order to maintain bcekup feed to tC01 4 bus in case the rormal fcco to tG01 bus were to fail. Ce Electrical Sepervisor nicurderstced what the shift supervicor ucs c. chir:g him. ne ua thinking that the Shift Supctvisor was referring to th3 fcct thct tha c c:3 feed frcn the Ib.1 ESP transformer (XNB01) told be left cnargittd tihich uculd letvo the line side of bre'aker 130212 energiced. E2 knau this ecs ccmon practica boccuse the only way this lino could be d:-cnergic:d t:culd bo to do-energizo tC01 bts, valch was not allcmd by n :hniccl Specificaticn. Tne Electrical Supervicor alco thetrht thtt tho Shift SeFatvicor was referring to the fact that the Fr c? bin 0t en 20212 C0uld ha clecned after the outcgo by tekirs tC01 doun cnd ac-energizing tha I:a..". CC7 trcasforrer (12301). Se Shift Supervisor ccde cut the c'tcrcn:c cad her.g the tags leaving Xtm02 cncrgized thinking that the olcetricc1 groep ur.derstcod and agreed to this. The following : corning at cpproximately 0730 hours, cno of the Electricel Incd Electricians went to the control roca cnd signed cn the clecrcr.ca. Eo tcok a copy of the clearance order back to the electrical ch:p, cc:fo ccpics, of the clearcnce order and placed a copy in ecch vorh p:ctc2 that m; ccir-] to the field to work. He did rot walk Ccwn cnS verify the cle :rcaco 5 ccuco ho expected the work group to do that. Tr.c dcy shift electricicn wha was in chcrgo of the scb ted the r0rk pcc:r: 2 to the field ctr3 verified the tags. 112 did rtat verify the clecranc: LEcir:a the cicetrical drea,ings to determine if the tcccut uns es ho capected it to be. Uc did pull the bceks ard fronts off cll the switchtecr cchinct; to chtc% with a hot stick and high voltcgo moccuring device to 000 if an%& wcs ctill enargized. He did not firr] cnything indicctirr; thct cn? cl t: 2 cc.bincts except for 200212 were encruit:d. t.t this poir.t, ho dccidd to perform a cecond check with another device (a glow ttte irrstrumr.t) to reverify if cny of the insulated conductors w:re enarjiced. Qis tre cf irstrtment does not rcquire direct contcet with a bcro cccductcr to inlicate that the conductor is energi-ad. It is a proximity Ccvice thct pic::a vp th2 electricci field. In order to encure that the inctre.cnt ws tx:::ir.3 properly, he pulled scme of the tolts off the IC0212 cabinct t6ich h2 Ic tw wcs still energir.cd and uscd the testor to verify this. Ec did not cce cny irvlication cgain that any of the cabinets were enertjiccd, co the crcw started to sgrk. The day shift e rked all day cleanirry cchincts, chec': ire breciers cr.d perfornire the work outlind in the week pcekcqcc. We feeder bred:erc frcu the ta02 leal center wc:s also bciry worktd on es a part of this of Tort, therefore, there was a good sizcd crew workirg in the arca all day, ne day
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,91201 SS/12/21 138 >l3 333 370rt WOdd i Page 2 F.vcnt *Mseription i i shift cc:apleted cicaning the cabinets down throtqh and including IE0209 by ena na W i.e .w i n. % a y,w.o.1.we.scsan in charr;a nr rha jeh cc::pleted his turnover form for nightshift. his is a form which is intended to infocu the night shift of the status of the jcb. 1:e turned his form in to his LeM E1ceteician and was told by him to get with the night shift Canior Electrician who muld be takiry over the jcb. I:c gwe a face to fcco turnover with the night shift Senior Electricicn cr.d gcVe hir.: the . *.= na w p i n m % niqw esi n coni,w pie ician i n rnn.w) his geple what they were going to be doing. ne told the a that the precedure was the scae one that they hM c:cd a fcw days beforc W.cn e hcd the PA 6.:s de.:n for elecnirs ard inspection, t:a hM the c co cro.i eer:dna 'en that jcb cr:d they had all reviewed the procedure ct that tico. So nicht shift stcrted work v;here the day shift left off. Tao dcy chift did r.cc do i any insp;cticn3 of the Pr cabinets beccuse thct ic la c Ccp;rtte F.rt of the-pnWure anr1 they plannad on doing P.her.1 n11 at the c:=n time. Oc nicht shift did not reverify the clearence or the c1cerence b:ctdcricc. Coy acct = d because so cuch work hM taken place during the dcy thct overythirta hM been checked out ard the jcb was safo. l The dcy shift hM picced signs on the 120212 cubicle Valch stcted "Ccuticn Cubicle I:nergized". These signa are not controlled by cny prcccdcre but were recently developed as an aid to the electrical g:cupa to ider.tify portiens of cwitchgocr that rc:nain onotriced. Oc night shift clich: hcvc gctten a faloc conce of occurity frcta ccoing thcca cign:: cn tho c.0212 cubicle but ncitere else. An 21cetrical Technician, wM was a centrcctor working fcr the cic:tric.1 g:cep during the outcge, uc3 cn top of the cwitetect clecairs M ce.bic1cc. U2 w a n r:: ira clo ely with and uMer the cepervicien of the Es.n ict Elcetricicn thct wcs the load person on the jcb. After cer?lttin0 th0 elecnir.g cnd incpections of the rc.?. air.dce of the ccbincts, they d2cid d to stcrt on the Pr cabinets, to Sznior Elcetricica unleched the M cdi'..t drecars cr4 pulled then out, ncse dre,;ers em crrc: red in cuch a tzcy E.u when the decacci are pulled out, they are do-ar.czdctd. no 21cettic;l T0chnicicn seggested that they pull the top; off the M ccbincts in crd: to do a better job of cicenin3 cnd inspecting. The Senior Electricien egrrd to this. %cy hed rc:noved the tops off tm Pr cchincts, clerr.M erd incpected thca, cnd diccovered whct cppecred to be occo miner cecc% liho irdiccticro in the insulating bushings. The Senior Electricica ccre dc.cn off the top of the switchgoar to go call liaintenance Creir.cori^;g to h:ve then cene to the field to look at the insulating bushiros. 22 ?.lcctrical Technician caid he would go ch?M and re cvc the tosc off tha next t o cabinets ard get started cleaning them. I 1 while the Senior Electrician was eckir.g the telephone cell, hc heard what he thoteht was scncone callirq for help. Ito inr:cdiately returned to the cabinet ard fourd the Electrical Technician layire face dca.n acrccs the top of tho l
1 1 S 'd 'LI:01 98/12/21 IBB >l338D 310f1 WOMd .i l s a Page 3 s { Event Description i s 3 cabinet with his arms apparently in the cabinet. Ile was uncenscious and had g apparently contacted 4160 volts in the cabinet which was ctill enegized fran Xia02. Several other electricians working in the area also heard the 1 cry and resporded to the scene. Sone of the electricians tried to p.tll him 5 free with belts, hoses, and anything else they could find, but were unable to do so. One man got on the Galtronics to tel.1 the control rec:n of the situation and that they needed to kill the power to the cubicle. The control room dispatched an operator to epco PA0201 beca'cor which was fccdir.g the cubicle. 'Ihe cperator found that PA0201 wc:s circcdy tripped w'. ten he arrived at the ccbinet. The injured racn's bcCy cyp;rer.tly p:cylded the fcult path to trip PA0201 at the time of the accident. In the ter.ntine, t.he halon syste:n discharged into the switchgear rocs which fcreed the pocple to evacuate the roon. m -i -.-~.4 .w .u... c4.~. 4 u se ~.4 a4 was declaring an dnusual Event. Wey alco called fct the Firo 3rigcZe to rcA to the switchgeer coorn. Se Fire Brigcde cer':ers freed the Wa!!ENII3N h5NEDhh2$5 WE.Nd bk$! than taken to the Ccffey (bunty Hocpitel for c crgency treatment. The Was Plant was rotified by the hospital sme titne later that the can had dicd of his injuries. Ems dasmeya did es ew en she ID02 e>tst ehgeaar as a reculb of tho' accident. Parts were not available to make the repairs i:nediately, therefore, a work request was she. v..a,,isa w...,generatal to make the repairs and parts were ,w 4
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,ettot 98/tz/zt taa M3383 370M W0ad y _L'G21 HIST. CIL"~'JrfIVE ACTICS TAW: .j %e wcrk we stopped on the switchgear at the time of the accident are was j 4 not allowed to restart until an assessment of the accident and its primary j causes evaluated and corrected. g 'the Plant Safety Committee met the following day with cognizcnt personnel in the maintencnoe group and thoroughly discussed the occic4. nt and its primary 1, causes. It was determined that the root cause of the accident wcs the i failure of the man to follow the work procedure which was overning the jcb. 3 l %c Maintuunce Procedure entitled "13.PRf and 4.16W Switchgear Inspectica and Tectire" (tee E0090-01), was the procedure being used to ccatrol tha work ectivity. Step 6.4.3 in the procedure urder the procedure cection cntitled "Potential Transformer Maintenance" states "ustro the high voltcsc gicies and tester, check the stationary disconnects for hish voltcso i potential. If no potential is found, check thct 'he high voltcso l connectic.1s ace discharg,xl." Wis step in the precedure is a preccutiona7 step in the pcxedureiwhich was to be accornpllded prior to performing any cleardag or irepection activities in the potential trcnsformer cabinet. It a is dwicus that this step was not followed ard had it been, would hcVe prewnted '.his accident. 1 %e committee decided that the Isr.cdiate corrective action which must bc tcJcer.: before work could be rectmed, was to make this step a mardatory sign off step. ne procedure was revised to incorporate this step as a marriatory, sign off along with a second double trei.ification signature. ) e l l l 1 g s 4
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,81 01 98/13/31 IBM N3303 370t1 WOBd i ( 1 a , _ ROOT _CP.USE(S) : We primary root cause of the accident was the failure of the man to folku the Maintenance Procedure governirv3 the work which required him to check the ? ntationary disconnects foe high voltage potential prior to doing any work in 's ( the Potential Transfomer cabinet. h l l %e F.lectrical Technician did not asc t.he soet basic electrical practice-that every electrician knows is a cardinal rule; "Oguipnent is always considered to be energized uncil pu e that it is not". tb electrical w rker should ever work on a piece o electrical equipucnt tntil he has Prwen that it is.* energized himself. Se failure of the wck stoup to perforn a campechensive pre-job briefing prior to starting the wach, en b:th shifts, was also a major factor in this s accident. i I \\ e \\ l e r 4
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Ida X3333 370n WOdd 1 Wr::TY3 Cr"SB: Ucrban or cep rvincru did not verify that the clearcnco was &cqacte or wh:.t t'.ny erpected by cc: paring the tagged cut equipnent listed on the clearcnco ordar against the electrical drawirrys. Everyone in the electrical i grcup v:3 erp:ctir:g *00212 to be enstgized becatse they know it is the cross Eced frcu the tG01 bus, but they were not expecting tG0209 to be energized crd they did not cht.0k thn clearance order to see if it was. 20 u00 of the "energized euhicle signs" apmared on the surface to be a scod idea bot may bcVe given the crew a falso sense of security in casunity th:t the cisas identified all the energized cubicles. W.e fccc iihct this jcb ha$ been worked all day by the day shif, ced had a larse portion of the work c:npleted, may have also served as a falce sense of cc:nrity to the night shift. Wat may have cane bearing on the roccon thct th y di6 rot reverify the clearance for th acivcc, which should have hun c routicu nomal practice. It is e:prent that scte electrical group personnel had baccro le:: in thole c p re.:h to tJrl:, stich in inherently dangerote if all the prope caCety proccuticns and sco$ work prce'. ices are int obsetvad. no Ec t that the injured man was a contecctor cnd may rot have 6:en i frallicr with the plant proccdures concerning work practices ca$ safety was i cne of the canarc irucstigatcd for this report. Wis concern was rot s Ccand to be substantiated because all the contractora are required to review, ca3 cica off that they have rea5 and urderstan$ the plant procedures which j i cover b: sic work practices cnd safety. nie is in addition to the traintry j they receive in Ra3 vbrker/Ger that everyono gets. Cocumented evidence c::ists thet exhibits that the injuros man did review at least twelve L,asic ( plcnt procedures which cover these types of activities. In addit'on, review { of op:cific plant procedures that cwer the job is accouplishe$ prior to ctarting work. As was noted earlier in the report, this man did review the spelfic kork procedure for this activity a few days prioe to the start of '} job s^ ten he p:rfor:aed a very similar activity on the PA bus an$ used the D woe procedure. 5 I a c o k e o
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-6130t 98/12/2I I88 >l33c 3lon WOdd ctr:CIv2 ActrS 'L'tu m Pice:r nt:Omrac2:: The 2ollowing corrective actions have teen taken to pecvent recurrence oC this tipe of event: 1. As an interim mecsure, the vice-President Nacicar chorations has written a acco for ctation distribution which mudatc3 that thorooch pre-jeb briefings chall occur on all work activiticc, in or out of an outacc. The pre-jeb briefirn will be es short or ac long as the job cc=ple::itico require and will incitric as a minuara the followirst a. Scfcty precactions for the job including the clearance order. b. 'Ihe cetual procedures or work instructions to be used will be
- rwicwed, A qc:raral disetesion of the job cmplexitics cnd potential probic::
c. 2 d. Taic function, or pre-job briefing, wiu repeat price to each chift starting work in the field if a job is cn on-going one. 2 Tae Plant l'enager tc~crarily suspended the Pafueling Ntwo becausa of this in::1 dent, cowled with three other incidenta, and merdcted thct cl'. sTh groups hold group meetirgs to diccats the cvants, the catncs, c.0 correctivo actiens. Tacco group meetingc wre held with all the 5.=% grran cad extensive discuscions with the gecups inclu::cd such key prcere:i elc ents as careful planning of our work, tcking the time to do i it right, and attention to detail. Tocco group discusciorc also concentrated on each lo31vidual's r%si,1bility to work safely, E crcuring that our p;cple are knowledgeable and couply with the work ' t hour limitations, the neocasity for paying attention to detail, p:rfc= ting a occ:prehensive pre-job briefing', ensuring that proper suparvisicri is maintained on the job end ensuring that all people ua$crstard the imipartance of strict guceare ccepliance. g e 3. Is n p,m:nant corrective action, the major administrative procedure i + (Atti 03-201) "Control of Maintenance ard Madifications", which defines 4 the policies and practices by which the plant controls maintenarv::e an$ codification activities, has been revised to incorporate tho ,9 requircemts es outlined in the susno's from the Vice-President h: lear operations ard the Plant Manager. ~ 4 u i ? h p 1
Ol'd 02:08 98/12/21 188 >l33d3 310M WO83 l C*:0W. _ ora 61c AcritrS *mmt: 1 C?catre of the fact that thic event was primarily doa to a failure to chacrvo good safety pec0tices, it 10 tot bellwed that this particular failuro, in any ucy, puto in quc3tien the quality of any of the Work perfor:00 on this job or any other job done previotely. During the course of tM inve:tigr. tion of this incident, there was no evidence that any of the cetual work performe$ was inadequate oc g rCormed in a notr-professional amncr which could jeopardize the proper functioning of any plant equipment. D/en thotnh this event did bring to light a failure to follow the proccoure step to check foe high voltogo potential before starting work, reno of the steps concerning the actual work were craitted. The procedure contains a ntnber of CC verification steps for veelfication and sign off by CC as well as the workmen. All work steps ard QC points were p*cperly cigned off ard a CC person wm present during all or mot of the work cetivities, I s t p 9 1 i 1 s; I 4
) Ii*d la1O! 98/12/21 188 >t3383 370M WOdd ,\\ y Attacreents to Report j 1. Copy of the Clearance Order 2. Copy of the 'Iurn:Not Fbrm used between day and night shift 3 Ccpy of the procedure swernirs the job which was in effeet at the time [ of the accident (tec E0090-01, Rev. 0). 9 4 4. Ccpy of the sate pro::cdure revised the day followirg the accident (MPE C0000-01, Rev. 1). '1 S. Copy of the hbrk wt anS procedure sign off clicets indicating the [ progrecs at the en$ of the day shift. 0 2 6 Oyj of the Eb1f Crec4 ultimate one line diagrca indicating the plant f cicetrical syste:n. (KD-7496) 0 7. Ccpy of the print indicating the tie in of breakers tG0209 and NB0212 to the t332 bus (E-011002(Q), Rev.12), e 'i G. C yy of the state:ncnts given by various plcnt personnel on the night of f the accident. /& 9. Ccpy of docuacnt that injured man signed stating he ha$ reviewed f various plant procedures. t 10. Ccpy of ms:o written tr/ Plant Mage suspending the refueling outage. b,
- 11. Copy of exo written by vicePresident 24Jclear Operations concerning pre-job briefings.
1 12 Copy of the hbek Roquest to repair 7c209 switchgear cubicle. OfR 0492-f G7) j' O 13 Copy of the Material Request ordering parts for the repair of NB209 y cubicle (tC# 2736) y
- 14. Cnvelope containire 47 pictures of tG02 switd) gear after accident f5
- 15. Picture of the "Cautia Cubicle Energized
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- 16. Copy of the accident form sert to Safety Department
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21*d tatot 88/12/31 188 >l3 383 d'10m Wolid 6 i b. Prossuriter Yv6tocen Burn On Octcher 14, 1987, at 9:15 a.m. the refueling ta:.: insido cont.aintant and HP personnel inside contain:::nt inforced the control ror-of a loud noise. A welder was welding on Valvo CD V-102, an j isolation valve to one of the pressurizer pressure /lcyr.:1 in-tru:ent sensing lines. He informad the control room thct t':n he struck an a arc for his second tack he heard a loud rushing sc,end, t:hich lasted 5 or 10 seconds. He also utated that the shoctcatal cover, tcped over the holo left when Valve CD PSV-80108 (a pressurizer code safoty valva) u:s rcn:oved for testing, was bicwn off by tha burn. Investigation by the licensee deterained that the.caly available 4 source of fuel for the burn was hydrogen in the veror space of th. l, pro::Uriser. The burn showed up on Control Rcce Lcycl decorder 03 LR-439 as a change of approximately 13 percent c: crease, a 2 percent j incNcso, and then. a return to the before burn icyc1 values. i The burn did not show up on the pressurizer pressure rc ctdcrs or the reactor coolant system (RCS) te.'perature recorders. H? c mpled the crea cf the code safety and determined that the cirborno activity icyc1s had not increased. hydrogen after the burn; ncce was found. Plant safety sa:mied the presurizer for ? investigation concluded that +'- The licensce's void space in tha -- bable source of hydrogen w:s the i 1 with T When the prcssurizer tras filled I push out hydrogen, enough i i ooe area so that when the FC
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9 hydrogen Icycl tus above the 4 4 .he upper instrtr. tent root valves n tt g g C. afeties being Naoved for j y[$7'N $ded to support a burn. Pr 4 tows that tne pressure pulse k in. / i [M g/ tely 30 psig. The licensee 't hai serfon::ed an inspection of the U spr /d af f. finding any evidence of dan yw e safety valve B3 PSV-8010A, j thit Engi 21d be removed and retested. vendi 1B-14 was written to have the I licer e presturizer, and the i proce nressurizer draindown licen:
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., required, corrective action, this will remainyeasible da have s an unr ..ec item (482/8727-02), c. Worker Fatally Injured I I, At 8:37 p.m. on October 14, 1987, an unusual event was declared 1 o because of a men being(NB02) roominjured and a fire in the Train '8" safeguards switchgear The man, an electrician', was the M802 switchfatally injured when he came in contact with energized termi0 1
- t The injured man wg'The fire turned out to be Hospital, where. gear.
he was pronounced dead. taken to Coffuy County. !j ,d q.
m.a amoi 99 tum T HH Y?m_ _-non uohd 7 1p I P 7 stoho frca demged electrical equip::ent related to the ccci(cat. The er.usu:1 cycnt was tor;aincted at 9:11 p.c., on Octob0r 14. H07. l The C302 suitchgocr had been tahen out of service and isolcted by I Clectrince Order 87-0076-!:B for a scheduled outage to cican, inspect, and test the equio=ent. ,;I l-Tha 41GO v AC safcguards pot:ce distribution systca bad tuo redundant [ busos,I:331 and I:002. Pcwor t'as sepplied to these buscs frca two ? cngineered safety featurcs (ESF) transforcers, Xtm01 and XI!B02. ESF Trcasfor:2r Xt:301 supplicd nora:1 power to (C01 thru Circuit h Drechar t.'30112 and alternato power to !!302 thru Circuit Broeker o ? I:30212. ESF Transforcer XtG02 supplied nornal perar to 1:302 thru Circuit Ursaker li30209 and alternate powar to 1:D01 thru Circuit is E i Brecher !!30109. These circuit breakers were located in c.bicles in 9 the C3 suitchgcar that they were feeding. The UE01 tad fig 02 ,f switch:ccr c.binets cro located in separato rooms, cnd the two syst:ns are indep:ndent of cach othar. [3 For the !CO2 c:intcn:nce outage ESF Transfort:r XCD01 eas kept p cncrgized in ordar to supply nor, mal pcwer to the I:301 bus, which was S supplying t:12 4160 v AC safety-related loads required ty Technical i! Specification. Having ESF Transformer XtBU* cnergized also energized F taa alternate feed to the f(002 bus, located in Cubicle tG0212. d Licenseo personnel also decided to keep ESF Transformar XtB02 it on 1:gized in order to provide an alternate feed to the safety loads r cacr 301. With ESF Transformar Xfm02 energized the normal feed to (: t302, located in Cubicle itE0209, was i.lso energ,ized. The operation: R shif t supervisor, nreparing the clearan;e order to isolate the HB02
- s switchestr discused on the telephone uitt; an electrical caintenance supervisor,the fact that both ESF Transforcers XIC01 cnd Xt:302 trould rectin on0rgized during the 1302 outage, and therefore the feedside of two cubicles,,f:30212 and 1:00209, in the 1:B02 suitchgcar would be cnergized. However, the electrical naintenance supervisor
=isund:rstood and thcught that only the foad side of the i:80212 c Sicle would be cacrgized during the TR02 outage. it d Prior to starting work on the day shift, electrical maintenance E personnel chec hd the switchgear with voltage detecting instruments f but failed to detect that Cubicle NB0209 was energized. "Caution / Cubicle Enstgized" labels were atMched to Cubicle (20212, but none 4 were attached to Cubicle HB0209. During the day shift, electricians c1 caned and inspected the cGicles and tested the circuit breakers in j Cubicle 1302 except for the tiB0212 cubicle and breaker. The day shif t personnel thought that Cubicle MB0209 was completely a h de-energized and performed the maintenance accordingly.
- 9 The night shift (5 p.m. to 3 a.m.) relieved the day shift and ik continued the NB02 maintenance work. The electrician who was killed 5
4 was working in a potential transformer cabinet which was mounted on i tcp of the MB0209 cubicle. The electricians were working on top of i p. i h 2
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h 'j the 1302 cubicles and had re=oved the cryers frc:1 the top of the i potential transformer cabinets. With the tcp off of IC0209 potential [ tecnsfortar cabinet, the energized, stationcry discont.cct tcrainals o that fed tha potential transformer were exposed. It was 04.se b exposed terminals that the electrician contacted. H Y The !$02 maintenance work was being accomplished in accordance with il Procedure MPE E009Q-01, Revision 0, "13.8 KV and 4.16 KV Switchgear b Inspection and Testing." 1 Licensee's Procedure MPE E0090-01 contained a number of steps that i sho.11d have identified the presence of high voltage in the MB02 cubicles. These steps are discussed below: h o Section 6.0 and 6.1 of M?E E0090-01 stated: P 1 "6.0 WO3 PERFOPJ'ANCE IllSTRUCTIO'lS i f:0TE: Recheck to take sure ell the su breakers to UTswitchgear, tie breaker, (if used)pp gh voltage supply breaker and soace heator breaker, arc OPEN. i High -voltage breakers should be in their racked down position. 3 .[ 6.1 Check the electrical drawings end identify any area (s) f which will have high volta f when the Bus is grounded. De Potential present even L i List the areas on the 1 l Attachment,"A* Sign-off Sheat." The only arca listed on Attachment "A" was "nB0212-Feeder from XNB01." fI o Step 6.3.9.3 stated: "Using high voltage gloves.and testor j check the rossettes to ensure that there is no voltage prcso,nt. j Check phase to phase, and phase to ground." The feed side rossettes should have been energized when the check was performed, but the voltage was not detected. y o Step 6.3.9.4 stated: "If no voltage was detected in 6.3.9.3 ensure that each of the high voltage connections is discharge,d." j If an attempt had been ande to discharge the feed sh t rossettes detected., the fact that they were energized would have been o Step 6.3.9.5 stated: "Clean the insulator and high voltage ~ .g. connection in each tube. Check the insulators for cratks and the rossettes for damaged fingers." s ? 1r D; 8 s
e ~. s st*d 18101 S1*d C3401 SL/12/31 IUM '3333 d*10M WO2d A 9 Step 6.3.9.5 was sic:ned off for Cubicle UB0209. This indiccted that peoplo performlng this step could havo been injured Steps 6.3.9.3 and 6.3.9.4 were apparently not adequately, since performed. Section 6.4 of IGE E009Q.01 provided the instructions for o performing caintenance on the potential transformers. Step 6.4.2 and the note preceding it stated: o "n0TE: Use cauti0n t; hen perfoming Step 6.4.2. High voltage potential c3y be present. 6.4.2 Recove bolted panals as neccesary to obtcin access to the stationary portion of the high voltage disconnects." o Step 6.4.3 stated: "Using the high voltage gloves end testor chech the stationary disconnects for hi h voltage potential.,.If r.o potential is found, check that the h gh voltage connections cre discharged." It was at this point in the procedure that the electrician was i injured c perforca,d.pparently without the above steps having been adequately 1 Pending further NRC review of this event and the licensee's task force findings, this is an unresolved item (402/8727-03). In addition reactor core, was lost for approximtely 17 minutesduring the above eve 6 operetors secured pcwcr to the itB01 bus in response, when the reactor 0 to the rescue evfort. Approxicately one-third of the fuel cssechlies were still in the reactor vessel at the tice and the refueling cavity was flooded up to 9tcator then 23 feet above the reactor vessel flange for the fuct transfer. This event did not result in any danger to the teactor plant. 6 d. Engineered Safety Features Actuations On October 15, 1987, degraded voltage on vital DC Buses HX02 and NK04 caused numerous ESF actuations. On Wednesday, October 14, 1937, the A g* 4160 v AC Bus HB02 was de-energized for routine outage siaintenancel this de-energized MG02 and HG04, which are the normal feeds to NK02 end NK04 With the normal feeds de-energized Batteries MK12 and itK14 picked up the loads on Buses NK02 aad N The licensee was aware of the batteries carrying the lo.d and we3 monitoring' bus voltage regularly in the control roca, but no specific gravities were taken to monitor battery capacity. The,1.icensee anticipated that 'c e HB02 would be returned to service prior to the batteries becoming l ) s r
%G aiiGKGLOH;LML:ANL LMi&G2GSGM.9lMcMkiK';Mg:kW} KGF-69, Rev. 5/87 h, PDR 6 OP 87-84 WCNCC Dats 10-19-87 PFOGRAWATIC DEFICIDCY REPORT Page 1 of 1 I l P A. Deficiency
Description:
B. Rep 3rted By: D/DR 87-103 Date: 10/19/ 87 R Phone: 2282 O SECTICN B On October 14, 1987, at 2022 an Electrician came in contact with i enert3 zed equipnent in the NB02 switchgear rom. Viis resulted in a i I L E fatality. M C. Programnatic Requirement: I Personnel safety. D E N E D. Initiate Corrective Acticr17: No W (Explain Below) Yes Q V A Identify Root Cause ard Corrective Actions necessuy to prevent SECTICN L recurrence. II U E. Individual Responsible for Corrective Action: M D Rich A T F. Potentially Reportable: No C Yes @ (Implement NDO III.17.0) I Ref. D/DR 87-103 0 G. Corrective Action Cmpleticn Date: 10/ 23/ 87 N P H. Innediate Corrective Actions Taken R O See Attached i B l L Date Ccrnpleted: 10 /15 /,8_7_ I E I. Root Cause(s): M See Attached SECTIO 1 R I III E J. Corrective Actions Taken to Prevent Recurrence: S O See Attached g U Date Ccmoleted: 10 /27 /87 T K. Pamedial Corrective Actions Taken: I O See Attached ) N Date Ccrnpleted: N/A/ / V L. All Corrective Actions Are Verifed as Acceptable Yes $ tb W (Explain) j E SECTICN R IV I F M. Individual Who Verified Corrective Actions: Q--)A R D Y L N. Division Mana3er Approval: Date: 10-29-O O ~~ "7 i SfrrRN S 0. Distribution: V U R e D us
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u a EVFWP DESCRIPTION: During the early evening shift on October 13, 1987, the Shift Supervisor was making out the clearance order to tag out the NB02 bus for switchgear inspection and testing which was scheduled to be perfomed the next day. We question came up if they srould tag out the tb.2 ESP transformer which 1 is the normal feed to NB02 bus. We Shift Supervisor called one of the i Electrical Supervisors and asked him if he had any problem leaving the tb.2 ESP transformer (XNB02) energized in order to maintain backup feed to NB01 bus in case the normal feed to NB01 bus were to fail. We Electrical Supervisor misunderstood what the Shift Supervisor was asking him. He was i thinking that tN Shift Supervisor-was referring to the fact that the cross feed fran the No.1 ESF transformer (XNB01) would be left energized which muld leave the line side of bre'aker NB0212 enetgized. He knew this was ccamon practice because the only way this line could be de-energized would be to de-energize NB01 bus, which was not allowed by Technical Specification. ne Electrical Supervisor also thotsht that the Shift i Supervisor was referring to the fact that the Pr cabinet on NB0212 could be cleaned after the outage by taking NB01 down and de-energizing the ib.1 ESP transformer (XNB01). Se Shift Supervisor ma3e out the clearance ard hung i the tags leaving XNB02 energized thinking that the electrical group understcod and agreed to this. The following morning at approximately 0730 hours, one of the Electrical Ima3 Electricians went to the control rcon and signed on the clearance. He took a copy of the clearance order back to the electrical shop, ma$e copies, of the clearance order and placed a copy in each work package that was going to the field to work. He did not walk down and verify the clearance because he expected the work group to do that. The day shift electrician wto was in charge of the job took the work package to the field ard verified the tags. He did rot verify the clearance against the electrical drawings to determine if the tagout was as he expected it to be. He did pull the backs and fronts off all the switchgear cabinets to check with a hot stick and high voltage measuring device to see if anything was still energized. He did not fird anythirg indicating that any of the cabinets except for NB0212 were energized. At this point, he decided to perform a second check with another device (a glow tube instrur.ent) to reverify if any of the insulated conductors were energized. nis type of instrument does not require direct contact with a bare corductor to indicate that the conductor is energized. It is a proximity device that picks up the electrical field. In order to ensure that the instrtrnent was working properly, he pulled scne of the bolts eff the NB0212 cabinet which he knew was still energized ard used the tester to verify this. He did not sce any irdication again that any of the cabinets were energized, so the crew started to wo,,rk. The day shift wrked all day cleanirn cabinets, checking breakers and performirq the work outlinnd in the wntk packages. De feeder breakers fron the NB02 loai center wm also beiry worked on as a part of this ef fort, therefore, there wu a govi sized crow workiry in the area all day. We day
W:&.n..;.;...;. \\.. ... m..n s x...p.. &.v. J.".k w.M. a.=:; :;, 3..u:.,n,, ;. 2. n;;.,FC.j : ; u'W..,.%..M. 1 W- . a., -u &, w.......,. n.. ~ .a .~ u .a. ..a c ~ !..c Page 2 l Event Description shift cmpleted cleaning the cabinets down through and incitding tB0209 by the end of their shift. We day crew electrician in charge of the job cmpleted his turnover form for nightshi f t. Wis is a form which is intended to inform the night shift of the statm of the job. He turned his i e I form in to his Imad Electrician and was told by him to get with the night shift Senior Electrician who would be taking over the job. He gave a face to face turrover with the night chift Senior Electrician and gave him the status of the job in progress. We night shift Senior Electrician informed his people what they were going to be doing. He told them that the procedure was the s ee one that they had used a few days before when we had the PA bus down for cleanire ard inspection. He hM the same crew workirg r on that job and they had all reviewed the procedure at that time. W e night shift started work where the day shift left off. te day shift did not do any inspections of the Pr cabinets because that is in a separate part of the procedure and they planned on doing them all at the same time. The night shift did not reverify the clearance or the clearance boundaries. Wey assmed because so much work had taken place during the day that everything i had been checked out and the job was safe. l The day shift had placed signs on the NB0212 cubicle which stated "Caution Cubicle Energized". R ese signs are not controlled by any procedure but were recently developed as an aid to the electrical croups to identify L portions of switchgear that reain energized. %e night shift might have gotten a false sense of security frm seeing these signs on the NB0212 cubicle but nowhere else. l An Electrical Technician, who was a contractor working for the electrical group during the outage, was on top of the switchgear cleaning FP cubicles. He was workire closely with ard urder the supervision of the Senior l Electrician that was the 1eM person on the job. After empletire the cleaning and inspections of the remairder of the cabinets, they decided to start on the Pr cabinets. We Senior Electrician unlocked the Pr cabinet j drawers and pulled them out. %ese drawers are arraaged in such a way that when the drawers are pulled out, they are de-energized. We Electrical Technician suggested that they pull the tops off the Pr cabinets in order to do a better job of cleaning and inspectirg. We Senior Electrician agreed i to this. %ey had removed the tops off two Pr cabinets, cleaned and l inspected thm, and disecnered what appeared to be sme minor crack like irdications in the insulating bushings. We Senior Ele ci lician came down off the top of the switchgear to go call Maintenance Ergineering to have them cm e to the field to look at the insulating bushings. We Electrical Technician said he muld go ahead and renme the tops of f the next two j cabinets and get started cleaniry them. ( While the Senior Electrician was makin) the telephone call, he heard what he j thotqht wm smcone callirq for help. He inmediately returned to the cabinet 1 and found the 21ectrical Technician layiry face down acrecs the top cf the l 1 I l l t L
'. n..L M :s s ' n c ;. w.: : w.4 2. E~~~L J ;.; J :L,+. ~;;.?W. ~;';. L... ;- ?%%2& ~ CTE*; l a a Page 3 Event Description cabinet with his arms apparently in the cabinet. He was unconscious and had apparently contacted 4160 volts in the cabinet which was still energized frm XNB02. Several other electricians working in the area also heard the cry and responded to the scene. Sme of the electricians tried to pull him free with belts, hoses, and anything else they could find, but were unable to do so. One man got on the Gaitronics to tell the control room of the situation and that they needed to kill the power to the cubicle. %e control rom dispatched an operator to open PA0201 breaker which was feedirg the cubicle. ne operator found that PA0201 was already tripped when he arrived at the cabinet. %e injured man's body apparently provided the fault path to trip PA0201 at the time of the accident. In the meantime, the halon system discharged into the switchgear rom which forced the people to evacuate the recm. The control rocm anrounced that there was a fire in the !E switchgear rom and was declaring an Unusual Event. %ey also called for the Fire Brigade to report to the switchgear rom. The Fire Brigade mertbers freed the injured man and brotght him out on a stretcher where they administered mouth to mouth resuscitation ard heart message until the ebulance arrived. He was then taken to the Coffey County Hospital for emergency treatment. The Plant was notified by the hospital sme time later that the man had died of his injuries. Scme danage did occur on the NB02 switchgear as a result of the' accident. Parts were not available to make the repairs imediately, therefore, a work request was generated to make the repairs ard parts were ordered. Wis work will be completed prior to puttire the plant back on the line. ~
Mi.;. I ~;. :X.CL2.= ' ":. Ji:DQ.c.:.,.,%J T ~>.k&:2,, 3. ' T ',2 ;-. !..*Nill 5 i.~l l. $.. 2 T. 'L D9EDIME CORRECTIVE ACTIGI TAKEN: We work was stopped on the switchgear at the time of the accident and was not allowed to restart until an assessment of the accident and its primary causes evaluated and corrected. We Plant Safety Ccmnittee met the following day with cognizant personnel in the maintenance group ard thoroughly discussed the accident and its primary causes. It was determined that the root cause of the accident was the failure of the man to follow the work procedure which was gcnerning the job. %e Maintenance Procedure entitled "13.8KV and 4.16KV Switchgear Inspection ard Testing" (MPS E0090-01), was the procedure being used to control the work activity. Step 6.4.3 in the procedure urder the procedure section entitled "Potential Transfomer Maintenance" states "usirg the high voltage gloves ard tester, check the stationary disconnects for high voltage potential. If no potential is found, check that the high voltage connections are dischaged." Wis step in the procedure is a precautionary step in the procedure which was to be acccxnplished prior to perfoming any cleaning or inspection activities in the potential transformer cabinet. It is c6 ious that this step was not followed and hM it been, would have prevented this accident. We ccanittee decided that the imediate corrective action which must be taken before work could be resmed, was to make this step a mandatory sign off step. We procedure was revised to incorporate this step as a mandatory, sign off alorg with a r.econd double verification signature.
MC;.'ai;.a u. a._',c:.:.%.:.62:bHM* :L?. ul?s&i'h:. ci.:.::w: t sX:3. :.d12Lha.* loor CAUSE(s): The primary rcot cause of the ageident was the failure of the man to follow the Maintenance Procedure gcuernirq the work which required him to check the stationary disconnects for high voltage potential prior to doing any work in the Potential Transformer cabinet. The Electrical Technician did not use the nost basic electrical practice that every electrician knows is a cardinal ruler "Equipnent is always considered to be energized until pu prove that it is not". No electrical worker should ever work on a piece of electrical equipnent until he has proven that it is not energized himself. '1he failure of the work group to perform a cmprehensive pre-job briefing prior to starting the work, on both shifts, was also a major factor in this accident. i l t 1 I i e I i j I i 4 i J
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q.; ?. - :.w ua u.a n..:,; a. u.a a,. u.a.: c y ~.,. n . '..,I " CONmIBttrIW. CAUSES: Wor)enen or supervisors did not verify that the clearance was Mequate or what they expected by ccrnparire the tagged out equipnent listed on the clearance order against the electrical deawirgs. Everyone in the electrical group was expectirg NB0212 to be energized because they know it is the cross feed fran the NB01 bus, but they were not expecting NB0209 to be energized an3 they did not check the clearance order to see if it was, ne use of the "energized cubicle signs" appeared on the surface to be a l good idea but may have given the crew a false sense of security in assuning that the signs identified all the energized cubicles. We fact Ehat this job had been worked all day by the day shift and ha$ a large portion of the work ccrnpleted, may have also served as a false sense l of security to the night shift. Wat may have sane bearirg on the reason that they did not reverify the clearance for themelves, which should have been a routine normal practice. l It is apparent that scrne electrical group personnel ha$ becerne lax in their approach to work, which is inherently dangerous if all the proper safety precautions and good wrk practices are not observed. W e fact that the injured man was a contractor and may not have been faniliar with the plant procedures concerning work practices and safety was one of the concerns investigated for this report. Wis concern was not found to be substantiated because all the contractors are required to revies, ard sign off that they have read and understand the plant procedures which cover basic work practices and safety. @is is in addition to the trainirn they rectiV9 in Rad Worker /GCT that everyone gets. D3cunented evidence l exists that exhibits that the injured man did review at least twelve basic plant procedures which cover these types of activities. In a3dition, review of specific plant procedures that cover the job is acecrnplisha3 prior to r startirg work. As was noted earlier in the report, this man did re/iew the specific work procedure for this activity a few days prior to the start of job when he performed a very similar activity on the PA bus and used the same procedure. i i I L i
2a. 5 5. A Y:?. 5 C E M 30.2$kdddh$3bk l. CORROCTIVE N:TIONS TNWN TO PREVENT RfXURRENCE: The followirn corrective actions have been taken to prevent recurrence of this type of event: 1. As an interim measure, the Vice-President Nuclear Operations has written a meno for station distribution which maMates that thorough pre-job briefings shall occur on all work activities, in or out of an outage. We pre-job briefing will be as short or as long as the job ccrmlexities require and will incide as a minimtrn the followirg: a. Safety precautions for the job including the clearance order. b. We actual procedures or work instructions to be used will be reviewed. c. A general discussion of the job conplexities aM potential pechlets d. %!s function, or pre-job briefing, will repeat prior to each shift stwrting work in the field if a job is an on-going one. 2. Se Plant Manager temporarily susperded the Refuelirg Outage because of this incident, coupled with three other incidents, and mandated that all work groups hold group meetings to discuss the events, the causes, and corrective actions. %ese group meetings were held with all the work group and extensive discussions with the groups inclWed such key program elements as exeful pl snning of our w>rk, taking the time to do it right, and attention to detail.
- R ese group discussions also concentrated on each individual's responsibility to work safely,*
ensuring that our people are krowledgeable and cmply with the work-hour limitations, the necessity for paying attention to detail, i performing a omnprehensive pre-job briefing, ensuring that proper supervision is maintained on the job ard ensuririg that all people understard the importance of strict procedure empliance. 3. As a permanent corrective action, the major administrative procedure (ADM 08-201) "Control of Maintenance ard W2ifications", which defines the policies ard practices by which the plant controls maintenance ard i modification activities, has been revised to incorporate the requirements as outlined in the meno's fran the Vice-President Nuclear Operations ard the Plant Manager.
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..,. 2 s. ~. i ;..-., .w..w .a~ ..~..:..... <v u.;6. .zu u.,. a ;., ... ~ i I REMEDIAL CORRECTIVE ACTIONS TAKDI: Because of the fact that this event was primarily due to a failure to observe good safety practices, it is not believed that this particular failure, in any way, puts in question the quality of any of the work performed on this job or any other job done previously. During the course i of the investigation of this incident, there was no evidence that any of the actual work performed was inadequate or performed in a non-professional manner which could jeopardize the proper functionirg of any plant i equipnent. Even though this event did bring to light a failure to follow the procedcre step to check for high voltage potential before startiry work, none of the steps concerning the actual work were onitted. 'Ihe procedure contains a nunber of CC verification steps for verification and sign off by CC as well as the workmen. All work steps ard CC points were properly signed off and a CC person wm present during all or most of the work activities. l l
QQ :... -. 3.J.5gQM;5;;-;.QC.?.KM'.( Attachments to Report 1. Copy of the Clearance oder 2. Copy of the Turnover Fbrm used between day and night shift 3. Copy of the procedure governing the job which was in effect at the time of the accident (MPE E0090-01, Rev. 0). 4. Copy of the see procedure revised the day following the accident (MPE E0090 01, Rev.1). 5. Copy cf the hbrk Request and procedure sign-off sheets indicating the progress at the eni of the day shift. 6. Ccpy of the 5 elf Creek ultimate one line diagram iniicating the plant electrical systen. (KD-7496) 7. Copy of the print indicating the tie in of breakers NB0209 and 20212 to the NB02 bus (L-01 NB02(Q), Rev.12). 8. Copy of the statements given by various plant personnel on the night of the accident. 9. Copy of docunent that injured man signed stating he had reviewed various plant procedures.
- 10. Copy of meno written by Plant Manager suspending the refueling outage, i
- 11. Copy of meo written by Vice-President Nuclear Operations concerning pre-jcb briefings.
- 12. Copy of the 'rbek Request to repair NB209 switchgear cubicle.
(WR 0492-87)
- 13. Copy of the Material Wt ordering parts for the repair of NB209 cubicle (MNr 2736)
- 14. Envelope containin] 47 pictures of NB02 switchgear after accident
- 15. Picture of the "Caution Cubicle Energized " signs i
- 16. Copy of the accident form sent to Safety Depart.wnt i
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u.n~ :.x m weLF f ( p N INTEROFFICEc CORRESPONDENCE NUCLEAR OPERADNG (, .,.'.',t, CORPOFMDON 2.'.~ >L i..: 7 (- .s . lIO: ,,.S. ta t i_o.n.'.Di s t. r. i. b.u t. l.6.n'.N: ,'. c ~ = .s .g . 'FRCH: [' . Gary.Bo er, (.. DATE: October 19, 1987 SUBJII:T: Suspension of Refueling Outage NO 87-0301 As you all know, we have temporarily suspended the refuelirx3 outage. In this memo, I will discuss why, and what we reed to do in order to resume work. For the most part, this outage has gone very well. The planning and preparation of work activities has been evident in their performance. In the last week, however, a nan has lost his life, and we have had three other incidents where potentially serious mistakes have been made. Individually, these three may not have warranted drastic action. Taken together with the e fatality, they are cause for alarm. We have suspeMed the out'ge to allow us time to complete our investigations of these events, evaluate the root causes, aM consider actions necessary prior to resumption of work. It will also give us a chance to reflect on our philosophy aM work practices, aM give everyone a rest. Therefore, while our investigations and evaluations are bMng performed, we have asked r I all organizations to meet individually aM review key elements of our program. These irclude the careful planning of our work, taking the time to do it right, aM attention to detail. These elements apply equally to management and employee. With the completion of our investigations and any corrective actions, we will initiate the resumption of outage activities. With the continued dedication and conscientious effort of all of us, we will c e plete the outage in a safe and efficient manner, and resume power operation. Your patience and support is apppreciated. Gary D. Bo - Plant Manager GDB/tlw Attach"'ent b.4
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a Attachmedt WO 87-0301 October 1.9,'1987 r j 'While'we'ars isfocusing.on our goals, this Ts 'an excellent' time to ' refresh ' ourselves on the 'way we should accenplish them: 1. Each individual has a responsibility to assure their own' safety. Never
- r begin a job if you are unsure of your ability to do it safely.
l 2. Each individual should be knowledgeable of the established Work-Hour l Limitations that are required for all personnel. Although there are exceptions, these should be kept to a mininum aM approved through the proper supervision. Keep in miM that a schedule is a target, a sequence of events which helps to coordinate the many activities that i must occur. This is what enables efficient work ard time savings. i j 3. Each job should receive the necessary Attention to Detail that not only achieves the end result, but ensures that the proper Job Briefing has occurred, proper Supervision of the Job is maintained, and the activity i is Done right the first time. i 4. In all work activities, Conply with the procedure. If the procedure doesn't work, is cumbersome, or is just too confusing: have it revised l before continuing the job. i We cannot urdo the loss we have suffered or change the events of the past. r i 6 l We CAN make ourselves Safer and Smarter! i i t i i I i ( l
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Ronn Smith (316)364-8831. ext. 2950 October 19, 1987 i Wolf Creek Operations Report Vol. 1. No. 15 October 13 - October 19. 1987 t Work on Wolf Creek Gcnerating Station's refueling and maintenance outage was stopped over the weekend to reexamine outage procedures and activities. The decision to stop work came as the result of four events which occurred at the plant last week. The events appear to be unrelated, and include the death of a worker as the result of an electric shock; a small resin spill inside the plant; ignition of a fis=mable gas during a welding operation; and unneeded activation of several safety-related systems. No radiation was released, and none of the events involved any risk to public health and safety. Wolf Creek Nuclear Operating Corporation (WCNOC) =anagement and employees have met to discuss events of the past week and factors l contributing to those events. The Nuclear Regulatory Commission has been and will continue to be consulted. Scheduled refueling and maintenance activites will resume after this reexanination process is complete. Some work is expected to begin by mid-week; full resumption of the scheduled activities will take at least several days. --more-- 4 b-9 57 i
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~u-t~u-n: - - - :;' - = - -<z p Y Most serious of last week's events occurred Wednesday, October 14, when 4 a contract employee working in an enclosed switchgear room was killed as the result of an electrical shock. Earlier in the week, a small amount of resin which contained some radioactivity was spilled inside the plant's radwaste building. It was confined to a small area of the building and was promptly cleaned up. There was no release of radioactivity to the environment and no threat to public health or safety. The thiro event last week occurred during a welding operation on the pressurizer, inside Wolf Creek's containment building. A small amount of hydrogen gas was ignited. There were no injuries and no apparent damage to plant equipment or structures. No radiation was released, and there was no threat to public health or safety. Activation of several safety-related systems occurred Thursday evening due to a drop in electrical voltage. The sytems functioned properly. No damage or injury resulted, however water from the cooling lake was pumped into a plant system used to generate steam under normal operations. There was no release of radioactivity and no threat to public health or safety. Individually, last week's events would probably not have led to the susper.sion of outage work activity. Taken together, however, the events were cause for Concern. Plant management's decision to reexamine procedures and activities was made to help assure completion of the refueling and maintenance outage in a safe and efficient manner. Duration of the outage will likely be delayed several days as a result. 0000 I .}}