Text

Forwards Formal Rept of Findings & Conclusions Re Investigation of Diesel Generator Failure,Per Jg Keppler to C Reed Transmitting Confirmatory Action Ltr
	ML20211G026
Person / Time
Site:	Zion File:ZionSolutions icon.png
Issue date:	02/06/1987
From:	Leblond P; COMMONWEALTH EDISON CO.
To:	James Keppler; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20211F781	List: IR 05000295/1986026; ML20211F776; ML20211F820; ML20211G026;
References
	2698K, CAL, NUDOCS 8702250257
	Download: ML20211G026 (44)
	v • d • e

{{#Wiki_filter:s {._ }.7 / Commonwealth Edison One First National Plaza Chicago, Illinois \\ / Address Reply t : Post Office Box 767 V Chicago. Illinois 60690 - 0767 February 6, 1987 Mr. James G. Keppler Regional Administrator U.S. Nuclear Regulatory Commission Region III 799 Roosevelt Road Glen Ellyn, IL 60137

Subject:

Zion Nuclear Power Station Units 1 and 2 IB Diesel Generator Failure NRC Docket Nos. 50-295 and 50-304

Reference:

October 27, 1986 letter from J. G. Keppler to Cordell Reed

Dear Mr. Keppler:

The referenced letter transmitted a Confirmatory Action Letter to Commonwealth Edison Company. This Order contained six items regarding the failure of diesel generator 1B at Zion Station on October 24, 1986. Item 6 of that letter required Commonwealth Edison Company to submit a formal report of the findings and conclusions regarding the investigation of the diesel generator failure. That report is enclosed with this letter. The report makes reference to a number of attachments containing photographs of the damaged diesel generator. These photographs have been previously supplied to Mr. James Muffett of your office. If any further questions arise regarding this niatter, please contact this office. Very truly yours,

p. C. LeBlond Nuclear Licensing Administrator im 8702250257 870218 PDR ADOCK 0500 5

O Enclosure cc: Zion Resident Inspector J. A. Norris - NRR 11 1987

TABLE OF CONTENTS PAGE TABLE OF CONTENTS i ABSTRACT 11 DESCRIPTION OF ENGINE AND GENERATOR 1 MAINTENANCE HISTORY 1 CHRONOLOGY OF TESTING PERFORMED 2 EYE WITNESS ACCOUNT 2 ACTIONS TAKEN 4 PARTS MAPPING 5 DESCRIPTION OF DAMAGE TO ENGINE AND REPAIR PROCESS 9 FAILURE ANALYSIS REPORT 11 WORK PACKAGE INVESTIGATION 22 POST ACCIDENT TESTING 23 CAUSE OF FAILURE 24 CORRECTIVE ACTIONS 25 REFERENCES 07760 i ,,--n----,,- ,-.n-,---nn--,, -,---.. - - -, - -.-wr-, w~---m,--s--mm _.--,--v ~

ABSTRACT On October 24,19861B diesel generator (DG) at Commonwealth Edison's Zion Nuclear Power Station experienced a failure during a post maintenance run. The failure resulted in the ejection of 4 left articulating rod arm and counterweight from the engine. Extensive damage resulted to the frame of the engine and other internal parts. No injuries resulted and because Unit 1 was shut down for refueling with the engine Out Of Service, no safety significance was involved. An extensive investigation into the cause of the failure was conducted by Commonwealth Edison Company. The Nuclear Regulatory Commission issued a Confirmatory Action Letter detailing steps to be taken by Commonwealth Edison Company and dispatched a special investigation team to the site. The investigation has concluded that the failure of the engine was caused by improper torquing of the lower articulating rod arm bolts. Short term and long term corrective actions have been taken by Commonwealth Edison Company. The failure was unique to 18 DG. l l l l I i 07760 11 l

DESCRIPTION OF ENGINE AND GENERATOR ENGINE MANUFACTURER COOPER BESSEMER MODEL KSV-16-T CYLINDER 16 STROKE 4 SERVICE DATE AUGUST 22, 1972 GENERATOR MANUFACTURER IDEAL ELECTRICAL COMPANY CAPACITY 4000 KW OVERLOAD RATING 4400 KW MAINTENANCE PERFORMED DURING FALL 1986 REFUELING MAJOR REFUELING OUTAGE WORK INCLUDED; REFUELING OUTAGE SURVEILLANCES, REPLACEMENT OF JACKET WATER AND LUBE OIL THERMOSTAT VALVES, AND REPLACEMENT OF LINERS, PISTONS AND PISTON RINGS IN 4L, 7L AND SR CYLINDERS. I l l l l l l l 07760 1 h_

.c. w, s CHRONOLOGY OF TESTING P,ERFORM'ED OCTOBER 24, 1986 1640 HOURS 18 DIESEL GENERATOR STARTED FOR INITIAL MAINTENANCE WALK DOWN. 1645 HOURS IB DIESEL GENERATOR SHUT DOWN TO REPAIR MINOR FUE'l OIL LEAK. 1800 HOURS 18 DIESEL GENERATOR RESTARTED TO VERIFY REPAlk 0F FUEL OIL LEAK AND TO COMPLETE MAINTENANCE WALK DOWN. 1815 HOURS MAINTENANCE WALK DOWN ON 18 DIESEL GENERATOR COMPLETE AND SATISFACTORY. ENGINE SHUT DOWN TO CLEAR OAD OUT OF SERVICE ON THE EXCITER FIELD BREAKER S0 TESTING COULD CONTINUE. ( 1850 HOURS 18 DIESEL GENERATOR STARTED FOR OAD TESTING. 1920 HOURS 1B DIESEL GENERATOR LOADED TO 1 MW FOR OAD TESTING. 2055 HOURS 18 DIESEL GENERATOR RUNNING AT 1MW, ABNORMAL KNOCKING HEARD FROM t LEFT SIDE OF ENGINE. ENGINE SHUT DOWN : LOCALLY.' ' ~ EYEWITNESS ACCOUNT The eyewitness report is from the Technical Staff DG System Engineer. 18 DG was running at 1 MW for modification testing following maintenance. An operator and I were in the roo;n with maintenance personnel outside. No abnormal noises or conditions were noted. The operator and I were standing in front of the generator panel with our backs to the engine reviewing the procedure for the next test to be performed, when we heard a single clank from behind us. It sounded like something had fallen near the generator or generator end of the engine. We immediately went to investigate the cause of the noise. We walked down the lef t side of the generator and engine on the ground level looking for the cause of the noise. No capse could be found. This inspection took approximately one minute. The operator'left the room and I climbed up a ladder to the inspection platform for the upper part of the engine. 0776o 2

I walked across the back of the engine and then along the left cylinder bank. When I reached cylinder 2L I heard a sof t knocking sound start. I immediately ran back down the lef t cylinder bank and across the back of the engine. The knocking sound increased in volume quickly and engine vibration could be felt. When I reached the right side of the engine the operator was running into the room and I signaled him to shut the engine down. While I ran down the inspection platform stairs, the operator continued to run to the panel and push the emergency stop button. The knocking continued to increase in volume. I ran from the room with the operator following immediately behind me. When we reached the door we turned, looked and saw parts being ejected through 4R cylinder and then the room filled with water, oil and steam from the engine. In a conversation with the operator following the damage, he indicated to me that the engine coasted down normally. The time taken to do the first inspection of the right side of the engine and generator was approximately one to one and a half minutes. The time taken to walk up the stairs and down the left side of the engine was approximately one minute. Af ter the initial knocking was first heard it was approximately ten seconds before the emergency stop button was pushed and another five seconds before the parts were ejected f rom 4R cylinder. l l l i 07760 3 l

~ AC110NS TAKEN -At about 20:57 on 10/24/86 1B DG was shutdown during a maintenance run due to unusual noises. As the engine was being shutdown the 4 left articulating rod and counterweight were ejected from the right side of the engine. The engine shutdown was normal and there was no fire or injuries. The shift operators took the engine out of service. The station duty officer was inf ormed. The station duty officer then informed the CECO duty officer, the Production Superintendent and the NRC Resident Inspector. A courtesy call was placed via the ENS phone to the NRC. Shift operations was instructed to post a guard on the entrances to the 18 diesel room, no parts were to be moved and oil absorbent cloth was to be placed over any parts external to the engine. A fire watch was also posted because of the quantity of oil on the floor of the diesel room. On 10/25/86 a conference phone call was held between Region III of the NRC and CECO. A Confirmatory Action Letter (REF 1 A) resulted. = Using photographs and drawings each part external to the engine was identified, located and tagged. Small parts were bagged-The parts were stored in QC hold areas. An NRC inspection team headed by Mr. James Muf fett arrived on site and all relevant written material related to the repair, maintenance, testing, and/or modification to 1B DG was made available to the team. A CECO investigation team headed by R. J. Budowle was formed to investigate the cause of the accident, repair the 18 DG to operable status and write a report on their conclusions and findings. The team interviewed the following personnel. TECHNICAL STAFF ENGINEER RESPONSIBLE FOR DIESEL GENERATORS MECHANICAL MAINTENANCE WORK ANALYST MECHANICAL MAINTENANCE PLANNER MECHANICAL MAINTENANCE MASTER MECHANIC MECHANICAL MAINTENANCE FOREMAN MECHANICAL MAINTENANCE WORKMEN QUALITY CONTROL INSPECTORS The debris and the 18 DG were inspected by CECO metallurgists. The articulating rod arm bolts were taken by SYSTEM MATERIALS ANALYSIS DEPARTMENT (SMAD) for failure analysis. The work packages for the 1B DG were reviewed by the team with assistance from CECO Quality Assurance Department. 0776o 4 l

~. 1B DIESEL GENERATOR ROOM 1.

4L ARTICULATING ROD 2.
4 CRANKSHAFT THROW COUNTER WEIGHT AND STUD 3.

MISC. #4R EXPLOSION 000R AND LINER PARTS--BY 1+2 4.

4R EXPLOSION COVER FLANGE--IN FRONT OF GENERATOR PANEL 5.

MISC. #4R EXPLOSION 000R FLANGE PART IN BACK OF ENGINE OF PANEL 6. MISC. ENGINE BLOCK DEBRIS EAST OF STARTING AIR COMPRESSORS ~ 7. EXPLOSION COVER PIECE BY EAST WALL 8. MISC. ENGINE BLOCK DEBRIS ON RIGHT SIDE OF ENGINE-FLOOR 9.

4R EXPLOSION COVER RELIEF VALVE ON RIGHT SIDE OF ENGINE

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PARTS MAPPING 18 DIESEL GENERATOR CRANKCASE 1.

4L PISTON PIN BOLT (STRETCHED) ON UPPER LEDGE OF ENGINE BASE 2.
4L CYLINDER PART---ON UPPER LEDGE OF ENGINER BASE 3.
4L ARTICULATING R0D BOLT WASHER 4.
4L PISTON PIN BOLT WASHER 5.
4L PISTON PIN BOLT WASHER 6.
4L ARTICULATING ROD BOLT WASHER 7.
4L PISTON PIN BOLT (STRETCHED) 8.
4L ARTICULATING ROD BOLT (STRETCHED) 9.
4L ARTICULATING ROD BOLT (SHEARED)

ALONG WITH THE PARTS LISTED WERE DEBRIS FROM THE THROWN ROD, INCLUDING, PISTON PARTS, CYLINDER LINER PARTS, AND CYLINDER LINER SEAL PARTS. THESE PARTS WERE MAINLY LOCATED IN THE 3L AND 4L CYLINDER AREAS OF THE CENTER FRAME. 1 i 1 07760 7

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I I DESCRIPTION OF DAMAGE TO THE ENGINE AND REPAIR PROCESS 1he 1B 'DG received damage to three areas during the f ailure, the left side cylinder block, the 4 right explosion cover, and the upper center frame of the crankcase. It was necessary to make repairs to all three areas. Attachment A is a view from inside the crankcase looking up at the number 4 left piston and cylinder block. 1 - indicates the cracks in the cylinder block 2 - the piston liner 3 - the piston 4 - the wrist pin A Cooper Bessemer field engineer was called in the day af ter the f ailure, to help determine the cause of the failure. It was suggested by the Cooper Bessemer engineer that we contact Reynolds French Corporation,.from Tulsa Oklahoma. Reynolds French has had success making similar repairs to other Cooper diesels. Reynolds French was contacted and came to the site to evaluate the damage. Upon completion of their investigation they submitted the proposed repair to CECO and Cooper Bessemer. When the repair was approved by Cooper Bessemer REF-18, the necessary parts were ordered, and station travelers were written to instruct and document the repairs. The first phase of-the repair program involved removing sli the paint from the damaged areas to allow non-destructive examination. After the damaged -areas were plotted, indications and surrounding metal were removed from the diesel. Again N.D.E. was performed prior to rebuilding, to ensure all indications were found. When this criteria was met, the restoration process began. The repair process involves bolting members into the frame and then using a combination of welding, metal stitching, master locking, and metal lacing to the bolted members as required. Metal stitching involves drilling several holes perpendicular to a joint line, removing the small web between the holes, and peening locks made of a high nickel alloy, into the holes. Attachment 0, lock 1 has been installed f and started to peen, lock 2 has just been set into the drilled slot and is ready to peen. i' 07760 9

O Metal lacing is performed on the joint line, between the cast iron and carbon steel plates. A series of predetermined sized holes are drilled and tapped, then a bolt is screwed in and bottomed out. Next, another hole is drilled so that it overlaps into the bolt that was just installed, and the process is repeated until the whole joint line is solid. The protruding bolts are ground off flush and peened, to form a smooth water tight joint. See Attachment E. 1 - the lacing process 2 - the new carbon steel bolted member 3 - the base metal 4 - the new carbon steel member being welded and laced Master locks are inserted at strategic locations to add strength to the built up members. A slot is milled across a joint or indication, then a piece of steel is fitted into the slot and metal laced. See Attachment F. Attachment G shows the left side cylinder block off the engine and turned upside down. Numbers "1" and "2" indicate where the cracks and surrounding metal was removed from the block. The carbon steel replacement sections have been installed as well as, (number 3), the stiffener. Attachment H shows the block with liners and wrinkle bellies installed after the completion of the recommended hydro. Attachment I shows the repaired explosion cover opening. The center frame area shown in Attachment J, looking towards the 4 right cylinder, has had the necessary metal removed to start reconstruction. In Attachment K the new members have been bolted into the existing structure, welded and metal laced in. An undamaged center frame web can be seen in Attachment L. The last part of the repair will require the recoating of the crankcase areas. 07760 10

~ Failure Analysis Report This section consists of two parts. The first part is a letter to the Zion Station Plant Manager from the CECO System Materials Analysis Department (SMAD) Metallurgy Group. This letter describes the 18 DG failure postulated sequence of events. The second part is a SMAD report detailing the results of the analyses performed on the 4L lower articulated rod bolt. This report concludes that this bolt failed from fatigue crack propagation. i i 07760 11

Novemb3r 5, 1986 Mr. G. Plisi Station Manager Zion Station

Subject:

Failure of the #18 Diesel Engine, #4 Left Cylinder On 10/27/86 and 10/30/86, inspections were perfonned on pieces removed from the #18 diesel engine, #4 left (4L) cylinder. The intent of these inspections was to reconstruct failed engine components and determine the probable component (s) and failure mode (s) which resulted in failure of the 4L cylinder. The inspections resulted in the following significant observations: 1) The lower right bolt attaching the 4L articulated rod to the #4 right (4R) cylinder piston rod had failed with a flat fracture morphology, indicative of fatigue induced crack propagation. 2) The lower left bolt attaching the 4L articulated rod the 4R cylinder piston rod had failed in ductile overload. This is evidenced by necking of the bolt resulting in a 525 reduction of cross-sectional area and a cup-cone final fracture analogous to that of a cosanon l tensile specimen. 3) The two bolts attaching the 4L articulated rod to the piston pin l exhibited reductions of cross-sectional area (i.e. necking) of 255 and 365 followed by tearing at a 45' angle of one bolt, and bending followed by tearing of the other bolt at a slant angle of about 45*. 4) The 4L articulated rod exhibited numerous indentations along its length and gross deformation of each end. the deformed ends probably occurred during contact with the crankshaft counterweights, piston, and cylinder liner after failure of the bolts The indentations to the other surfaces were caused by contact with other 4L and 4R cylinder components, and during ejection of the articulated rod from the engine. 5) The #4 cylinder front end counterweight had fractured catastrophically into four, large identifiable pieces. The largest of these pieces had been ejected frms the engine. 07760 12 e ,_--,,-,_,_t-_.--_,.__,,__-_-,._,__,_._____-.,,_--

6) Each counterweight is fasten:d to the crankshaft by two long bolts. In the fractured counterweight, one of the bolts had failed in shear, along its intersection with the crankshaft to counterweight nating i surfaces. The other bolt was bent at a 90* angle (parallel with the direction of rotation), but remained attached to the crankshaft. 7) Piecing together of the counterweight fragments revealed extensive deformation of the leading surface. This damage is thought to have occurred by repeated contact with the lower end of the 4L articulated rod prior to failure of the counterweight. Repeated contact of the counterweight with the articulated rod is the probable initiator of the counterweight's fracture. 8) The rear counterweight exhibited extensive deformation of the leading surface, similar to the failed front counterweight. A two inch long crack is present in the leading corner of the fit to the crankshaft. 9) The 4L piston and cylinder liner were fractured and pieces missing j along the crankcase end. This is believed to be consequential damage that occurred by contact with the articulated rod after failure of the lower bolts and during and after failure of the upper bolts. l Based upon the observations stated above and a detailed visual and ~ microscope examination of selected failed, components, the following failure scenerio is proposed:. ~ ~ 1) The lower right bolt attaching the 4L articulated rod to the 4R piston rod failed by low cycle fatigue induced crack propagation and ~ was ejected from the rod into the engine crankcase. Optical and scanning election microscopy revealed the fracture to be primarily (approximately 80%) quasi-cleavage induced by transgranular fracture; I this is characteristic of fatigue crack propagation. Approximately 20% of the fracture surface consisted of ductile tearing resulting from ductile overload after the fatigue crack had progressed to the extent that the remaining ligament could not carry the load. 2) After failure of the one lower. bolt by fatigue fracture, the entire operating load was transferred to the remaining lower bolt. This bolt began to yield, resulting in bolt elongation and reduction of cross-section area. Yielding of the lower bolt may have resulted in non-uniform distribution of operating loads to the upper bolts joining the articulated rod to the piston pin. 3) The remaining lower bolt failed due to ductile overload, freeing the I 4L articulated rod from the 4R piston rod. 0776o 13 li l :.

4) The detached lower end of the articulated rod was struck numerous ~ times by both crankshaft counterweights. During the course of these contacts, the articulated rod was wedged against the cylinder liner and the upper rod bolts overloaded. One or both of the upper rod bolts failed in a shearing, tensile overload. The cylinder liner and piston were also fractured by contact with the articulated rod. 5) During the repeated impacts with the articulated rod, the badly i damaged front counterweight had cracked at the corner of the leading edge fit to the crankshaft (the rear counterweight was also cracked in this area). The crack in the front counterweight grew and linked with the mounting bolt hole. When the crack reached critical size, fast fracture occurred through the mounting bolt hole. This separated the counterweight from one mounting bolt and suddenly - transferred the load to the second bolt. The sudden loading of the second bolt caused it to shear, thus f reeing the counterweight f rom the crankshaft. The largest counterweight section impacted the engine block and 4R crankcase explosion door, fracturing both, and exiting the engine. 6) Damage to'the engine block internals and the 4R cylinder components resulted from contact with the fractured counterweight sections and the freed 4L ' articulated rod, prior to its ejection from the engine. The above sequence of events _is postulated based upon evidence gained from l visual inspections of failed components and limited destructive evaluation of one lower bolt. The complete results of this destructive evaluation will be presented in a report to be issued upon completion of analyses. Neil J. Mares SMAD - Metallurgy Group cc: M. P. Madigan J. F. Reiss 14 07760 I t

M-5286-86 12-4-86 SYSTEM MATERIALS ANALYSIS DEPARTMENT REPORT ON FAILURE OF THE LOWER ARTICULATED ROD BOLT FROM THE IB DIESEL ENGINE AT ZION STATION A metallurgical investigation was performed to determine the cause of failure in the lower right articulated rod bolt from the IB diesel engine at Zion Station. The failure occurred during a routine performance test of the generator in October, 1986. This analysis was performed as a follow-up investigation into the cause of failure of the IB diesel engine (see SMAD meno dated November 5, 1986 to Mr. G. Pliml-Plant Manager). The bolt is specified as 1 3/8 inch diameter ASME SA 193 Gr B7, and is one of two bolts used to attach the 4L articulated rod to the 4R piston rod (see Figure 1). The failure of the bolt was caused by fatigue crack propagation. Visual Examination The articulated rod bolt had fractured through the threaded region, as shown in Figure 2: this section of the bolt was submitted for analysis. The second piece remained in the 4R cylinder piston rod. I The bolt's fracture surface was predominantly flat in appearance over approximately 80V of the cross-sectional area, the remaining 20% of the fracture surface exhibited a ductile appearance. The fracture surface is shown in Figure 3. A thumbnail shaped region was observed on the fracture surface, emanating from a thread root. Numerous crack ledges were observed at this location and are indicative of multiple crack initiation sites. The thumbnail appearance and extent of flat fracture imply l l 15 . =-

M-5286-86 Paga 2 fatigue crack initiation and propagation under undirectional bending with low nominal stress in the presence of a mild stress concentrator. An examination of the fracture surface with the aid of a scanning electron microscope revealed a quasi-cleavage (ie. transgranular) fracture morphology as shown in Figure 4. The ductile region had a fibrous texture (ie. cup and cone) appearance. Meta 11urcical Evaluation A chemical analysis of the failed bolt identified it to be an J AISI type 4140 alloy steel. The complete chemistry is presented in Table 1 and shows the bolt material meets the SA 193 Gr B7 specification. Samples removed for metallographic evaluation revealed a tempered martensite microstructure from the core to the surface of the bolt. The suspected failure initiation site was a thread root, as shown in Figure 5. The bolt threads had been roll formed, and no pre-existing flaws (ie. laps or seams) were observed. Hardness tests performed on the failed bolt indicated a hardness of 24 to 29 Rockwell 'C' scale. i Conclusion l The lower right articulated rod bolt failed from fatigue crack l propagation. This is based on the flat fracture morphology and l l thumbnail appearance observed on the fracture surface. The composition and hardness of the failed bolt were within the ASME SA 193 Gr B7 specification. I i i 16 i

M-5286-86 P0g3 3 Inadequately torqued bolts will result in an increased susceptibility to fatigue crack initiation (ie. reduced fatigue life) because of insufficient pre-load. This suggests the articulated rod bolt had either loosened in service or was inadequately torqued at the time of installation. The manufacturers specified torque value for this bolt is 1140 foot-lbs. (o corre<-{s eus s 9nAJLR n /2/2.tgf i l l Approved by: /) /h;4 Reported by: 'll ',- A. e Y Copies to: G. P. Wagner </ K. L. Greasser G. Plial B. Johnson R. Cascarano M. Madigag 16.1 18310 17

M-5286-86 Pcgo 4 Table 1: Chemial Composition of the Failed Lower Articulated Rod Bolt from the IB Diesel Engine at Zion Station ASME SA193 GR B7 Element (Wt. %) Rod Bolt (AISI 4140) Carbon 0.37 .37.49 Manganese 0.91 .65-1.10 Phosphorus 0.011 0.035 Sulfur 0.073 0.040 Silicon 0.25 0.15-0.35 Nickel 0.19 NS Chromium 0.92 0.75-1.20 Molybdenum 0.19 0.15.25 Copper 0.09 NS NS-not specified i i l \\ l l 18 i.__._,__ _ _ -,. - _ -. _, - - - - - - - - - - - - - - - -. - - - -. - - - - - - - - - - - ~ > - - - - - - - - - - - - - - - - - - - - - - - - -

M-5286-86 l Page 5 SMAD Report on Failure of the Lower Articulated Rod Bolt from the 1B Diesel Engine at Zion Station l l i w i <,] I = - ---. -- Figure 1 The location of attachment o; the articulated rod to the piston rod. Sections of the two, failed rod bolts remain in the piston rod. The section remaining in the hole to the left side in the photo corresponds to the bolt submitted for analysis. The bolt section remaining in the hole to the right in the photo failed from ductile overload. 19 l

M-5286-86 Page 6 SMAD Report on Failure of the Lower Articulated Rod Bolt from the IB Diesel Engine at Zion Station l K zz _;..; l = emnetr._ b@~ '.D-5 g .m sv.w u c Figure 2 The as-received section of the lower articulated rod bolt from the l 1B diesel engine at Zion Station. The locking tab on the bolt is bent upward. The arrow points toward the fracture surface shown in Figure 3. ( i ?i+

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M-5286-86 i Page 7 l SMAD Report on Failure of the Lower Articulated Rod Bolt from l the IB Diesel Engine at Zion Station ,.s k _, %._ s f' i ~. 11 ( \\ \\ --..i.. i, ~ \\ / %r 3 f- ? } ?y/ i \\ 'y l/. J s 4, 3 ; ( Q:' f t'<lt l )1;..u w$ '~ -2. i 'w . h, ,y,.. j.. s ~y %' s . r r p/ . '3 1 i t-u l / 1,, t,~ p s s 1000x ~, Figure 4 l Scanning electron photomicrograph showing the quasi-cleavage l fracture morphology in the flat fracture area of the bolt. rp . ~.,,,N : '- e*>;~j.p.::Y cp@.,p'. p'2;, . c. 7 ,0 .w .s. ' T. $ Yj'- .u'5 s

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WORK PACKAGE INVESTIGATION As part of the 1B DG failure investigation, all work packages associated with the 1B DG maintenance during the current Unit 1 outage were reviewed by the Ceco Quality Assurance Department to determine if there were any deficiencies other than inadequate work instructions which might have led to the failure of the 18 DG. It was concluded that the Maintenance foreman had performed an inadequate review of the work packages involved. These work packages had signoffs that were not complete by the workman and hold points not signed off by QC. The usage of several different but overlapping procedures resulted in nine hold points not being signed off and no traceable documentation that they were complete. Discussions with QC personnel indicated a high degree of assurance that the QC inspections were all completed. It was determined that these incon.plete signof fs did not cause or contribute to the failure of the Diesel Generator. Oi?60 22

Post Accident Testing 18 OG will be started and loaded for an extended run of 24 hours. The load will be maintained at 4 MW for a minimum of 22 hours and at 4.4 MW for an additional 2 hours. The 2 hour rating of the generator is 4.4 MW. Following the 24 hour extended run, load will be reduced to 4.0 MW for a load rejection test. The load rejection is accomplished by opening the diesel generator output breaker and verifying that the diesel generator is running unloaded. Along with these tests the normal monthly surveillance test (PT-11) will be performed. Af ter successful completion of these tests the 18 OG will be declared operable. Additional testing will be performed on 18 DG which can only be done with Unit 1 in the hot shutdown mode. These tests will entail the starting and loading of 18 OG to 4.0 MW until the engine temperatures stabilize. At this time the engine will be unloaded and secured. Immediately after engine shutdown the 1B OG will be placed in standby status and a simulated Safety Injection (SI) and dead bus start will be performed. This requires SI loads to sequence on the bus. The 18 DG will be shutdown and placed in standby again. A simulated loss of offsite power start will be performed and Blackout loads will be sequenced on the bus. Successful completion of these additional tests will conclude the 18 DG return to service testing. I 0776o 23 i l

o CAUSE OF FAILURE It quickly became evident from the work package instruction, conversations with workmen and from examination of the lower articulating arm bolts that one of the lower bolts had failed from insufficient torque. The work instructions did not specify the torque value for the lower bolts because the work analyst assumed'that the articulating rod could be left in place during maintenance. Only the torque value for the upper bolts was specified. The mechanics removed the articulating rod and piston per the prescribed method in the Cooper Bessemer Maintenance Manual. The work analyst did not consult the manual. The torque value specified on the work package was used to torque the lower bolts because the head size of the upper and lower bolts was the same and th.Techanic assumed that they were torqued to the same value. In fact these bolts were non-standard bolts and did not have the same diameter. This resulted in the lower articulating rod bolts being under-torqued. This was the cause of the failure of the 18 diesel generator. The torque values for the lower articulating rod bolts for the 0, 2A and 28 diesel generator were then checked and any bolts that moved with less than 1140 f t-lbs of torque applied were replaced. This failure is unique to the 18 diesel generator. l 0776o 24 l r

e SHORT TERM CORREC11VE ACTIONS The short term corrective actions were to check the torque values on the lower articulating rod bolts for all diesel generators. Any bolts that moved with less that 1140 ft-Ibs of torque were replaced. All Quality Control Inspectors were required to read and sign a policy statement on hold points, which stated, a hold point "should be signed on the job as soon as possible after the inspection required is performed." Every safety related work request will be reviewed for adequate work instructions including those already in progress. For safety related work requests, jobs that involve instructions covered in a technical manual, will have a traveler attached. i Their will be no deviations f rom the scope of work without the proper procedure approval. Work will not be considered finished for any reason without all sit.1 offs completed, hold points satisfied, and documentation complete. A group headed by the Assistant Superintendent for Technical Services interviewed all individuals that were involved with the maintenance of the 1B DG. Discipline was then recommended for individuals who did not follow procedures or good work practices. Disciplinary measures were conducted by the Station Manager. T-l l l l 07760 25 i 1

e ~ LONG TERM CORRECTIVE ACTION A Commonwealth Edison team was formed to review the quality of maintenance at all CECO nuclear stations. This team was augmented by two consultants with comprehensive nuclear maintenance experience. The results of this review will be discussed with all Maintenance Assistant Superintendants in January 1987. 4 f 1 i I l i 0776o 26

CAL-R111-86-006 - umise st.ts: -[ g"g OCT 2 8 W NUCLEAD CE ULATORY COMMIS$10N f A nacion m g g m. = mv... .. au ..u. m %e.- OCT 271986 Docket No. 50-295 eaa THIS DOCUMENT Comonwealth Edison Company REQUIRES A ATTN: Mr. Cortiell Reed Vice President WRITTEN RESPCNEE. Post Office B 7 SUBMIT A DRUT RISPCNsg Chica90. I NO LATER.ThAN om Gentlemen: This letter confirms the telephone conversation between Carl J. Paperielloaf' this office and Ken Graesser and George P11m1 of your staff on October 25, 1986, related to the failure of Diesel 1-B during a post-maintenance test at the Zion Station on October 24. With regard to this event and to our Special Inspection which is being conducted to evaluate the root cause and significance of the event, we understand that you will: 1. Determine the cause of the failure of Diesel 1-B. 2. Before cleaning up the diesel generator area, record the location by means of photographs and/or drawings of all parts and components ejected from the diesel. 3. Advise the team leader. Mr. James Muffett, of this office prior to conducting any disassembly or repair activities on Diesel 1-B. Such notification will be soon enough to allow time for the team leader to assign an inspector to observe the activities. 4. Make available to the inspection team all relevant written material related to the repair, maintenance, testing, and/or modifications to diesel 1-B. This should include maintenance records and work orders. QA records and any records that might identify personnel who performed work on Diesel 1-B during the current Unit 1 outage. 5. Determine if this failure was unique.to Diesel 1-B or if a similar problem could occur on the other Cooper-Bessimer diesels at the Zion site. 6. Submit a formal report of your findings and conclusions to the Region III Office with 30 days of the conclusion of your investigation. Please let us know imediately if your understanding differs from that set out l above. Sincerely. CLmbMa-d% l fJamesG.Kepp1Itr" Regional Administrator See Attached Distribution 3 References lA CONFIRMATORY ACTION LETTER

Consnonwealth Edison Company 2 OCT 271986 CAL-RIII-86-006 cc: D. L. Farrar. Director of Nuclear Licensing G. J. Plim1, Station Manager Jan Norris, Project Manager, NRR DCS/RSB(RIDS) Licensing Fee Management Branch Resident Inspector, RIII Phyllis Dunton, Attorney General's Office, Environmental Control Division Mayor, City of Zion e la e e CONFIRMATORY ACTION LETTER

r 7 .f. It O i o November 13, 198'6 l l Ceaumonwealth Edison Company Zion, Illinois l Attention: Gary Fanning, RE: E5V-16-T Zion Unit 1B ) We have reviewed the fourteen (14) pages of updated repair proposal aketches transmitted to us by Reynolds-French via telecopy on 11-12-86. These sketches outline repairs to be made to the left bank cylinder block and to the centerframe of this engine in the number 4 throw area. In additicri to the work outlined on these sketches, the following is required: 1. The damaged area of the right hand outboard rib on the generator end crosawall of throw #4 in the centerframe should be ground smooth and blended into the remainder of the rib. The remaining material should be inspected to insure that there are no remaining cracks. 2. All repairs to gasket surface areas should be machined to restore a flat l gasket surface following locking and lacing. i 3 The repaired cylinder block abould be' hydrostatic tested at 50 pais per C-B i specification SD-47 before it is reinstalled on the engine. If the repairs are carried out in accordance with the referenced sketches and 4 notes above, to the complete satisfaction of Reynolds-French and. Company, it is i our opinion the repaired cylinder block a~nd centerframe will perforia as well as l the original undamaged components under all expected engine operating l conditions. j Cooper-asemer Reci roosting Products kf. John N

rne, er Analytical and Compressor Engineering i

JMH/saa cc: Reynolda-French and Company l Tulas,' (klahoma Attention: Wallace. Johnson i l Glenn Miller - MV I

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ML20211G026

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ML20211G026

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