ML19325F178

LER 89-015-00:on 891009,diesel Generator 1R43-S001B Failed to Start Manually During Monthly Generator Test.Caused by Personnel Error & Incorrect Model Number Assigned to Pump. Pump Replaced & Oil Drained from cylinders.W/891106 Ltr

ML19325F178
Person / Time
Site:	Hatch
Issue date:	11/06/1989
From:	Hairston W, Tipps S GEORGIA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
HL-803, LER-89-015-02, LER-89-15-2, NUDOCS 8911150103
Download: ML19325F178 (9)

Text

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%' ' N 7333 L Georgia Power Company Pc1mont Avenue ,

I- D *' * "W . * = Atlanta. Georg:a 30308 ]

. g; - Telephorie 404 526 3195 '

, Maing Address -

.u% ' 40 inverness Conter Parkway

+, Post Offce Dax 1295

, . Birmingham, Alabama 35201

> i' Telephone 205 868 558J ~

t!e souttwvn m:ke sn tem 1

W. G. Hairston, lit i Senior Vce President l Nuclear Operations 0362V l 1 I November 6, 1989 I s .

O.S.! Nuclear Regulatory Commission '

' ATTN: Document Control Desk .I Hashington, D.C. 20555 1

PLANT HATCH - UNIT 1  :

NRC DOCKET 50-321 ,

i OPERATING LICENSE DPR-57 LICENSEE EVENT REPORT ,

DIESEL GENERATOR 1B INOPERABLE DUE TO INSTALLATION OF INCORRECT PART -

Gentlemen:

In accordance with the requirements of 10 CFR 50.73(a)(2)(i), Georgia Power Company .is submitting the enclosed Licensee Event Report (LER) concerning the inoperability of the IB diesel generator due to the installation of an incorrect part. This event occurred at Plant Hatch -

Units 1 and 2.

Sincerely, 1

g.h., $Y _ ,)}p H. G. Hairston, III 1

JKB/eb

Enclosure:

LER 50-321/1989-015 c: (See next page.)

8911150103 891106 PDR S

ADOCK 05000321 PDC rh tg a

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i E (Jecngia Potver Abbi

'U.S. Nuclear Regulatory Commission November 6, 1989

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c: Georaia Power Company Mr. H. C. Nix, General Manager - Nuclear Plant Mr. J. D. Heidt, Manager Nuclear Engineering and Licensing - Hatch GO-NORMS U.S. Nuclear Regulatory Commission. Washinaton. D.C.

Mr. L. P. Crocker, Licensing Project Manager - Hatch U.S. Nuclear Reaulatory Commission. Region II Mr. S. D. Ebneter, Regional Administrator Mr. J. E. Menning, Senior Resident. Inspector - Hatch r

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• U s. NUCLE AA kE1ULATORY COMMISSION

• , APPROvtD OMS NO. 3166-0184 LICENSEE EVENT REPORT (LER) **a'*8"

PACILITY 8eAME Hi DOCKET NUMBER 121 FAGE G PLANT HATCH. UNIT 1 0161010101312 D 1 loFl 017 ftTLS 646 l

D/G 1B INOPERABLE DUE TO INSTALLATI0k 0F WRONG PART GVSNT DATE Ill LER NUMBER (61 REPORT DATE 17) OTHER P ACILITIES INVOLVED (el l MONTH DAY YEAR YEAR N n

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OPE RATING THIS REPORT IS SusMITTIO PUREilANT TO THE REQUIREMENTS OF 10 CPR l- (Casc4 ene er aiore of she fonowmal lit) 8800E m) 20.402(bl 20 406(el 90.731sH2H6,1 73.71M 1 _ _ _

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.lCENSEE CONT Af17 FOR THIS LEtt H2)

NAME TELEPHONE NbMBER ARE A CODE Steven B. Tipos. Manaaer Nuclear Safety and Compliance. Hatch 911I2 31617 I -17 i 81 Sil j COMPLETE ONE LINE FC R EACH COMPONENT FAILURE DESCRIBED IN THl0 REPORT H31 lE CAUS$ system COMPONENT M $ AC. R{ORTAgg

, pq CAUSE sv8 TEM COMPONENT "Aj[ R y,RTpnA E f s s

i i i I i i i i i i I i i i I i l i i I I I I I I I I SUPPLEMENTAL REPORT EXPECTED 114) MONTH DAY YEAR YES (If ven. temple,e txPECTIO SU049tS$1CN DATEI 9*O l l l A T R ACT a , . ,. . . ,,...e-, , , . -,,. , , n .,

L On 10/9/89 at approximately 0900 CDT, Unit 1 was in the Run mode at approximately 2436 CMWT (approximately 100% of rated thermal power) and Unit 2 was in the Refuel modo with all fuel removed from the core. At that time, procedure 34SV-R43-002-23, " Diesel Generator 1B Monthly Test," was being '

performed. While attempting a local, manual start of Diesel Generator (D/G) 1R43-S001B per procedure, the D/G failed to start. Subsequent investigation revealed that approximately two gallons of lubricating oil had accumulated between the pistons of the number 2 cylinder, hydraulically locking the pistons. The oil accumulated as a result of an incorrect type of pump that

, had been installed in the D/L's standby circulating lubricating oil cystem on 9/5/89. Monthly operability testing of D/G 1R43-S001B was completed satisfactorily on 9/15/89, ten days after the incorrect pump was installed and placed in service. Therefore, it is concluded D/G 1R43-S0018 became inoperable at some indeterminate point between 9/25/89 and 10/9/89. The other four D/Gs were not affected by this event.

The root cause of this event is personnel error. The incorrect model number had been assigned to the warehouse stock number for the circulating lubricating oil punip MPL number. Consequeritly, the incorrect type of punp was issued and installed.

Corrective actions for this event include replacing the pump, draining the lubricating oil from the cylinders, visually inspecting the D/G, correcting the model number assigned to the pump's stock number, changing the required functional test for pump repair / replacement, and performing a review of a sample of D/G parts information.

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. U.S. NUCLEA](.E!ULAroRY COMMr5SION l UCENSEE EVENT REPORT (LER) TEXT C NTINUATION . mr.ovco oue wo sino-oio4 EXPIRES: t/31/N f; @LirY agamt (gg DOCMt1 NUMSSR W LOR NUMSER le) PA06 (3) , 1

'E + m. u um ., =g PLANT HATCH, UNIT 1 o l510 lo io i 31211 81 9 0 11 'l 5 -

010 01 2 oF 017 rext ;., - . = w anc e m on PLANT AND SYSTEM. IDENTIFICATION General: Electric -' Boiling Water Reactor

~ Energy' Industry Identification System codes are identified in the text p .as'(EIIS. Code XX). l l . 1 SUMI1ARY OF EVENT L

OnL1 0/9/89 at'approximately 0900 CDT, Unit 1 was in the Run mode at approximately 2436 CMWT (approximately 100% of rated thermal power) and I Unit 2 was'in the Refuel mode with the Reactor Pressure Vessel head  ;

removed, the cavity flooded,'and all fuel removed from the core. At '

that time, procedure 34SV-R43-002-25, " Diesel Generator 1B Monthly Test,"'was being performed. While attempting a-local, manual start of Diesel Generator' (D/G, EIIS Code EK) 1R43-S001B per procedure, the D/G

' failed'to start. Subsequent investigation revealed the D/G was-

. hydraulically . locked. Approximately two gallons of lubricating oil had accumulated between the pistons of the number 2 cylinder, locking the j

' pistons. The oil ' accumulated between the pistons as a result of an - 1 incorrect type of pump that had'been installed in the D/G's standby l circulating lubricating oil system (EIIS Code LA) during maintenance  ;

activities. performed on 9/5/89. Monthly operability testing of 'D/G l

-1R43-S001B was completed. satisfactorily on 9/15/99, ten days after the

~

'irtorrect pump was installed and placed in service. Therefore, it' is

. concluded D/G-1R43-S0018 became inoperable at some indeterminate point between. 9/25/89 and 10/9/89. The other four D/G's were not affected by

.this event.

The. root cause of this event is personnel error. The incorrect model number had been assigned to the warehouse stock number for the standby circulating' lubricating oil pump (EIIS Code LA). Consequently, the incorrect' type of pump was issued from the warehouse and installed.

. Corrective actions for this event include replacing the pump with the correct type of pump, draining the lubricating oil from the cylinders, V!sually inspecting the D/G, correcting the model number assigned to the pap's stock number, changing the required functional test for pump upir/ replacement, and performing a review of a sample of D/G parts information.

DESCRIPTION OF CVENT On 9/4/89, Maintenance Work Order (MW0) 1-89-3940 was initiated on the Standby Circulating Lubricating 011 Pump,1R43-C006B, for D/G 1R43-S001B (1B D/G) to correct excessive tripping of the supply breaker. On C/5/89, Maintenance personnel found that the cause of the breaker tripping was a defective motor. In removing the defective motor, the pump had to be disassembled. As an alternative to rebuilding the pump, it was decided to replace it with a new pump. Accordingly, Maintenance

esac Poem ageA U.S. NUCLEM 051ULAv0RY COMMISSION

'" M ' LICENSEE EVENT REPORT (LER) TEXT CONTINUATIEN er;.ovto ove' No. am-om s tXPIRES S/31/98 F AClLifV NAMS (H DOCRET NUMBER W LER NUMetR 10) PA05 (31 -

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PLANT 4ATCH. UNIT 1 015101010 l 31211 81 9 011l5 -

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, personnel completed Stock Material Issue (SMI) requests for a new pump l L - and motor from an on-site warehouse. They obtained the stock numbers '

, corresponding to the. replacement pump and motor for pump 1R43-C006B and l entered that information on the SMI requests. This is per plant ,

l procedure for obtaining parts from the warehouse. Warehouse personnel,' l when given the properly completed and approved SMI requests, located the  ;

pump and motor by the given stock numbers and issued them to the  :

requesting Maintenance personnel, j l

Maintenance personnel installed the new pump.and motor in the 1B D/G's j standby circulating lubricating oil system. They then performed a 1 functional test of the new pump by verifying no oil flow into the upper )

crankcase per procedure 52PM-R43-013-0S, " Diesel Engine Main and  !

Connecting Rod Bearing Inspection." Two maintenance foremen '

independently verified " oil not flowing into upper crankcase." The pump was placed into service.and the 10 D/G was declared operable. Monthly operability testing of the 1B D/G was completed satisfactorily on 9/15/89.

On 10/9/89, Operations personnel began the performance of procedure 34SV-R43-002-25 as part of another scheduled surveillance of the 1B D/G. At approximately 0900 CDT, a local, manual start of the D/G was  !

attempted as required by the procedure. The D/G failed to start. l Another attempt was made to start the D/G, but it also was unsuccess ful . The 1B D/G was declared inoperable and Limiting i Conditions for Operation (LCOs) 1-89-477 and 2-89-511 were initiated.

l Maintenance personnel began an investigation of the start failure. They manually rotated the D/G crankshaft, but could produce only 1/4 turn of 1 the crankshaft. This indicated the D/G was hydraulically locked. Upon inspection, it was discovered that approximately two gallons of lubricating oil had accumulated between the opposed pistons of the number 2 cylinder. This locked the pistons and prevented the engine ,

from starting. Approximately 20 gallons of lubricating oil also was I found in the cylinders' exhaust line.

Further investigation revealed pump 1R43-C006B was continuously pumping oil into the upper crankcase. Although the pump is designed to run j continuously, the discharge head developed by the pump should be '

insufficient to allow oil to reach the upper crankcase at oil temperatures above 102*F (normal oil temperature is approximately 135*F; the pump trips if oil temperature drops to 105"F).

The model number of the installed pump was checked and found to be .

incorrec'. The installed pump was a model HL75M rated at 20 gpm rather I than the correct model H75M rated at 10 gpm. The incorrect pump had been installed on 9/5/89 when the pump and motor were replaced. The other four D/Gs were checked and found to have the correct pump installed in their standby circulating lubricating oil systems,

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The stock. number assigned to pump 1R43-C006B showed both pump model numbers, H75M and.HL75M; as appropriate. Both models were stored in the same location in-the warehouse and, because they were both assigned to the same stock number, were consideted acceptable for issuance as a i replacement for pump 1R43-C006B. Both models were tagged with stock number 87120-30918 and MPL number 1R43-C006B. When the pump.and motor were issued on 9/5/89, personnel obtained a pump tagged with the stock number and MPL number given on the SMI request. l

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[ The outward appearance of the two pumps is almost identical. The only difference is slight (one end face of the model H75M pump is' recessed 1

approximately one inch, the same end face of the model HL75M pump is almost flush) and is not obvious without a detailed inspection. The overall size and shape of the two pumps are the same, consequently, tne -

model HL75M pump fit into the standby circulating lubricating oil

. sy stem. When the incorrect pump was functionally tested, it was thought that no oil was flowing into the. upper crankcase; however, oil flow is slow (on the order of a few drops per minute) and is difficult to detect.

The lubricating oil was drained from the cylinders and the exhaust lir.e, pump 1R43-C006B was replaced with the correct model (H75M), the 1B D/G was visually inspected with no damage identified, procedure i 34SV-R43-002-1S was successfully performed, and the D/G was declared '

operable at approximately 0140 CDT on 10/12/89. LCOs 1-89-477 and 2-89-511 were terminated.

CAUSE OF THE EVENT '

The root'cause of this event is personnel error. The incorrect model number (HL75M) was assigned to the warehouse stock number for pump 1R43-C006B. .This resulted in model HL75M being tagged for use as Standby Circulating Lubricating Oil oump 1R43-C006B. Consequently, the incorrect model was issued and installed as pump 1R43-C006B on 9/5/89.

It is inconclusive as to when the stock number was incorrectly assigned.

Also contributing to this event was a less than adequate functional test on 9/5/89. The functional test for the new pump was performed using a portion of procedure 52PM-R43-013-0S. It consisted of removing the upper crankcase inspection covers and visually verifying no oil flow into the upper crankcase. This functional test method is less than fully adequate since it is very difficult to detect oil flow of the small magnitude experienced in this event.

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.G-LICENSEE EVENT REPORT (LER) TEXT C3NTINUATl3N U S. DeUCLE AR RIOUL' TDRV COMW9510N ;

urRo<eo ous No.sisowio.

(KPIRE$. 8/31/N PACILITT fBAMS til DOCKt." NUhIDER 40 ttR NUhtttR tel l PA06 (3) via "$!.T "'#si PLANT HATCH, UNIT 1 0151010101312 l1 81 9 Ol115 -

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REPORTABILITY ANALYSIS AND SAFETY ASSESSMENT i This report is required by 10 CFR 50.73'(a)(2)(1) because a condition l existed which was prohibited by the plant's Technicel Specifications.

l I

'Specifically, the 1B D/G was inoperable for an indeterminate period of time between 9/25/89 and 10/9/89 without the appropriate actions being taken as required by Unit 1 Technical Specifications section 3.9.B and .i Unit 2 Technical Specifications section 3.8.1.2. l

'In this event, the 10 D/G was inoperable due to the accumulation of lubricating oil between the pistons of the number 2 cylinder as a result <

of an incorrect type of. pump being installed in the standby circulating  !

lubricating oil system. The 1B D/G provides emergency power to Unit 1 or Unit 2 emergency equipment in the event of a loss of offsite power

.(LOSP). Each unit also has two other D/Gs which provide emergency power to redundant emergency equipment in the event of an LOSP.

During the time period in question, 9/25/89 to 10/9/89, Unit 1 was at full power with its other two D/Gs,1R43-S001A and 1R43-S001C operable.

Therefore, two Unit 1 D/Gs were operable and one was not. This l

condition has already been analyzed in Unit 1 Final Safety Analysis '

Report (FSAR) section 8.4.4. A detailed analysis of a loss of coolant accident in conjunction witn an LOSP and the loss of one D/G is given in Unit 1 FSAR section 14.4.3. It was determined that "with one diesel out of service, the remaining diesel generator units are capable of furnishing power for safe shutdown" of Unit'1. Based on existing analysis, it is concluded this event had no adverse impact on Unit l's nuclear safety.

During the same time period, Unit 2 was in the Refuel mode with no fuel in the vessel. Fuel movement was in progress in the Spent Fuel Pool curing a portion of this time. Unit 2 Technical Specifications require at least one D/G to be operable under these conditions. This requirement was not met for an indeterminate period of time from 9/25/89 to 10/1/89 when neither D/G 2R43-S001A (2A) nor D/G 2R43-S001C (20) was operable. D/G 2A was operable from 10/1/89 to 10/9/89.

There are two events which could occur during the Unit 2 conditions stated above: a fuel handling accident and a loss of Spent Fuel Pool inventory. In a fuel handling accident, a spent fuel bundle is dropped during movement resulting in damage to the bundle and releases of gaseous fission products. This, in turn, would result in high radiation levels on the Refueling Floor and automatic start of the Unit 1 and Unit 2 Standby Gas Treatment (SBGT, EIIS Code BH) system filter trains. Even if this event were to occur in conjunction with an LOSP (a highly unlikely event), D/G 1 A and 1C wnuld provide emergency power to the Unit 1 SBGT system. The two Unit 1 SBGT system filter trains are adequate to maintain offsite doses within analyzed limits (see Unit 1 FSAR section 14.4.4 ).

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UCENSEE EVENT REPORT (LER) TEXT C2NTINUAT12N - geRono ous wo. mo-oio4 i EXPtRES: t!31/M PACIUTY 88AME m DOClltiNUMSER W LER IdVMSIR 40) . PA06 (3) u*a .

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PLANT HATCH. UNIT 1 o is lo l0 lo l 312l1 8l 9 -

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. A loss of Spent Fuel Pool invento'y r is an analyzed event (Unit 2 FSAR section 9.1.2.3.1 ) . If such an event were to occur concurrent with an ,

LOSP, emergency power would be needed to power safety related pumps to l 1 replace the lost SFP water. Due to the design of the Spent Fuel Pool, l pumps powered by the 1 A and 1C D/Gs are capable of providing makeup to l

the SFP.

Based on the above, it is concluded this event had no adverse impact on Unit 2's nuclear safety. Had this event occurred with Unit 2 at full power (as Unit 1 was), it would have had no' adverse impact on nuclear safety since the 2A and 2C D/Gs would have been operable (they were out i of service for outage related work which would not have been performed during operation). As on Unit 1, one D/G out of service has been analyzed on Unit 2 (Unit 2 FSAR sections 8.3.1.1.3 and 8.3.1.2.1) and found not to prevent safe unit shutdown. Therefore, this event would not have been worse had it occurred under other conditions.

CORRECTIVE ACTIONS The lubricating oil was drained from the cylinders and the exhaust line,  !

pump 1R43-C006B was replaced with the correct model (H75M), the 1B D/G l was visually inspected with no damage found, procedure 34SV-R43-002-1S was successfully performed, and the D/G was declared operable at approximately 0140 CDT on 10/12/89. At that time LC0's 1-89-477 and 2-89-511 were terminated. Additionally, it was verified the correct model pump was installed in the standby circulating lubricating oil systems of the other four D/Gs.

The incorrect model number was deleted from the stock number for the standby circulating lubricating oil pumps and assigned its own unique stock number. The two types of pumps were physically separated. They now are stored in different locations in the warehouse. The tags on the pumps were corrected to reflect the change in stock numbers and intended use.

The affected portion of procedure 52PM-R43-013-0S will be revised to change the steps used as a functional test to make them more meaningful and easier to perform (e.g., verify pump discharge pressure within acceptable range). These changes will be made prior to use of the procedure as a functional test following repair / replacement of the pump.

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LICENSEE EVENT EEPORT (LER) TEXT CENTINtlATl!N APPa veo oue NO.3160 -0104 4 l5h'E EXPIRES: 8131/ND PActL47V $$Atllt til DOCR4T NUtdBER (3) Ltn tsubseta tel PA06 (3) u*a "Mr.;',', ' ' "trf,7 PLANT HATCH, UNIT 1 o ls [o lo lo l 3l 2 l1 819 -

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TfxT M mese auss, e mousset use senseener Nec Perm m W (In l

As of December 1988, stock numbers are assigned by plant Nuclear Procurement Review Group personnel at the time of equipment requisition review while performing procedure 26MC-MTL-006-0S, " Requisition Review for Quality Requirements." However, a review of a 10% sample of U/G l parts on file will be performed by 3/1/90 The review will check the i part records for MPL number, stock number, and model number to ensure I

this information is correct and the part's intended use is properly identified. Further corrective actions (e.g., expanding sample size, 4 physical walkdown of D/Gs) may be taken based on the results of the review.

Since the persons responsible for assignment of the erroneous stock number could not be identified, no disciplinary actions have been taken against any individual.

ADDITIONAL INFORMATION No systems other than the 18 D/G were affected by this event.

No similar events in which a safety system was rendered inoperable due 1 to the installation of a wrong part were noted. I