05000316/LER-1978-037-01, /01T-1:on 780615,both Diesel Generators Placed in Condition Where Neither Engine Capable of Automatic Start. Operator Closed & Tagged Out Starting Air Pilot Valves on Wrong Diesel Generator.Operator Reprimanded

/01T-1:on 780615,both Diesel Generators Placed in Condition Where Neither Engine Capable of Automatic Start. Operator Closed & Tagged Out Starting Air Pilot Valves on Wrong Diesel Generator.Operator Reprimanded

ML20128C348
Person / Time
Site:	Cook
Issue date:	06/29/1978
From:	Baker K INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:
Shared Package
ML20128C304	List: 05000316/LER-1978-037, Forwards Revised LER 78-037/01T-1 Which Rescinds Commitment to Run Emergency Diesel Generator While Other Diesel Generator Being Removed from Operable Status.Change Will Reduce Number of Fast Cold Starts 05000316/LER-1978-037-01, /01T-1:on 780615,both Diesel Generators Placed in Condition Where Neither Engine Capable of Automatic Start. Operator Closed & Tagged Out Starting Air Pilot Valves on Wrong Diesel Generator.Operator Reprimanded
References
LER-78-037-01T, LER-78-37-1T, NUDOCS 8505280269
Download: ML20128C348 (8)

LER-1978-037, /01T-1:on 780615,both Diesel Generators Placed in Condition Where Neither Engine Capable of Automatic Start. Operator Closed & Tagged Out Starting Air Pilot Valves on Wrong Diesel Generator.Operator Reprimanded

Event date:
Report date:
3161978037R01 - NRC Website

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.0 EVENT DESCRIPTION AND PROSABLE CONSEQUENCES Oio gl UNIT OPERATING IN MODE 1.

BOTH EMERGENCY DIESEL GENERATORS WERE PLACED j

gi IN A CONDITION WHERE NEITHER ENGINE WAS CAPABLE OF AUTOMATIC START IN l

ITTTl i VIOLATION OF APPENDIX A TECHNICAL SPECIFICATION 3.8.1.1.

THE TWO INDEPENDENT l o s 1 0FFSITE POWER SUPPLIES WERE AVAILABLE AND OPERABLE FOR THE TWO HOURS AND l

81 54 MINUTES THAT THE EMER. DIESEL GENERATORS WERE IN0PERABLE.

THIS IS THE o i i FIRST EVENT OF THIS TYPE.

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43 44 47 CAUSE OESCRIPTION AND CORRECTIVE ACTIONS El THE AUXILIARY EQUIPMENT OPER OR CLOSED AND TAGGED OUT THE STARTING AIR i

i i l PILOT VALVES ON THE AB EMER DIESEL GEN INSTEAD OF CD EMER DIESEL GEN BY i

l MISTAKE. DOORS TO ALL 4 EMER DIESEL GEN P00MS WERE LABELED. AUXILIARY m l' EQUIPMENT OPERATOR WAS REPRIMANDED.

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SHIFT OPERATING PERSONNEL BY OPERATIONS SUPERINTENDENT.

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SUPPLEMENT TO LER 78-037/01T-1 Paga 1 of 7 (A)

Description of the Event:

In Mode 1 the Emergency Diesel Generators are normally L

lined up for automatic start and loading if required.

.At-1109 hours on June 15, 1978 the CD Emergency Diesel Generator (EDG) was started. manually and paralleled with the system because it had been reported there was a fuel oil leak on an injector.

The CD Emergency Diesel Generator was stopped at 1153 hours0.0133 days <br />0.32 hours <br />0.00191 weeks <br />4.387165e-4 months <br /> after locating the fuel leak.

The l

"AB" Emergency Diesel Generator was started manually at 1213 hours0.014 days <br />0.337 hours <br />0.00201 weeks <br />4.615465e-4 months <br /> to verify its operability as required by Technical Specification 3.8.1.1 Action a.

The "AB" Emergency Diesel Generator was stopped at 1322 hours0.0153 days <br />0.367 hours <br />0.00219 weeks <br />5.03021e-4 months <br /> after being proven l

operable.

Clearance Permit 9350 was prepared by the Shift Operat-L ing Engineer (SOE) at 1345 on June 15, 1978 to place the l_

CD-EDG out of service to repair the leaking injector.

The SOE gave the Clearance Permit to the Unit Supervisor (US) for performance.

The US instructed the Auxiliary Equipment Operator (AEO) to hang the clearance Tags.

The CD-EDG output breaker control switches located in the Unit 2 Control Room were placed in the " Pull to Lockout" position L

by the US and the AEO placed the tags on the control switches.

Placing the circuit breaker control switches in the " Pull to Lockout" position prevents any automatic signal from starting i

j the engine.

The AEO then proceeded to the EDG rooms to close and place tags on the Starting Air Pilot Valves for l

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S SUPPLEMENT TO LER 78-037/01T-1 Pcga 2 of 7 the engine.

The Starting Air Pilot Valves were being closed to prevent being able to start the engine manually.

The AEO entered the wrong EDG room and closed and tagged the Starting Air Pilot Valves for the AB-EDG.

The four tags for Clearance Permit 9350 were recorded as being in place at 1351 hours0.0156 days <br />0.375 hours <br />0.00223 weeks <br />5.140555e-4 months <br /> on June 15, 1978.

The Maintenance Man who was to repair the leaking fuel injector recorded he checked and accepted the Clearance Permit at 1410 hours0.0163 days <br />0.392 hours <br />0.00233 weeks <br />5.36505e-4 months <br /> on June 15, 1978.

The Maintenance Man made the repairs and released his clearance Permit at 1620 hours0.0188 days <br />0.45 hours <br />0.00268 weeks <br />6.1641e-4 months <br /> on June 15, 1978.

By this time, the Operating Shift had changed and a new shift was in charge of the plant.

The SOE directed the US to have the clearance Permit Tags picked up and the circuit breaker control switches and Starting Air Pilot Valves returned to their normal position.

The US directed the AEO to remove the tags from the CD-EDG Starting Air Pilot Valves and to open the valves.

The AEO entered the CD-EDG room and found the Starting Air Pilot Valves open and no tag on them.

He immediately reported this to the US.

The US directed the AEO to check the AD-EDG to see if the tags were incorrectly placed.

The AEO found that the AB-EDG Starting Air Pilot Valves had been closed and tagged.

The AD-EDG valves were recorded as open at 1645 hours0.019 days <br />0.457 hours <br />0.00272 weeks <br />6.259225e-4 months <br />.

Placing the CD-EDG control switches in the " Pull to Lockout" position prevented the CD-EDG from automatically starting and loading on a demand signal.

Shutting the L

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SUPPLEMENT TO LER 78-037/0lT-1 Pcga 3 of 7 Starting Air Pilot Valves on the AB-EDG prevented air from starting the AB-EDG on any signal, manual or automatic.

Therefore both the AB-EDG and CD-EDG were inoperable in violation of Technical Specification 3.8.1.1 for a period of three hours.

(B)

Cause of the Event

The primary cause of this event was operator error by the AEO.

The AEO mistakenly entered the wrong EDG room and closed and tagged the wrong Starting Air Pilot Valves.

Secondary causes of this event were (1) the signs to identify the EDG rooms had not been made and installed.

Most of the rooms in the two Units are mirror image from the center line of the plant.

This is not true of the EDG rooms.

In both Units the AB-EDG room is to the right of the center line and CD-EDG is to the left of the center line.

Also the first door off the hallway a person comes to on Unit 1 is the AB-EDG room and on Unit 2 the first door off of the hallway is the CD-EDG room.

The Maintenance Man involved in making the repairs verified the tags correctly placed in the Control Room but did not verify the tags correctly placed on the Starting Air Pilot Valves.

This would not have prevented the event but would have reduced the amount of time that both EDG were inoperable.

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M SUPPLEMENT TO LER 78-037/0lT-1 UPags 4,-of - 7 +

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CorrectiveActionTake&AtTNmAEventTWasDiscovered y-v The US directed 1the AEO7to check'the A3-EDG to see if'

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. y the wrong Starting A1,r, Pilot valve had 'beeig shut.

The

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s AB-EDG Starting air; Pilot Valves Uere immddiately opened and 3

the tags whie removed > Th( CD-EDG was started at 1655 hours0.0192 days <br />0.46 hours <br />0.00274 weeks <br />6.297275e-4 months <br /> s

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and paralleled with the system.',,~There(were no more fuel oil leaks and the CD-EDG was declar$d operable at'1807 hours0.0209 days <br />0.502 hours <br />0.00299 weeks <br />6.875635e-4 months <br />.

OpeningtheStartingAir"EllotValvesha(r$kioredthe

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- se AB-EDG to an operable. condition.

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.rn (D)

Safety Evaluation of the Event

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.y The Emergency Diesel Generators' provide esbackup to the l

e two Technical-Specification required'independerft off-site transmission networks.

Throughoutsthin event both of.these 3.<.

A cff-site. transmission netwo'rks were opdrable and the circuit breaker lineup as required by Technical Specification 4.8.1.1.lahadbeen,p$rformedwithinkhereqsiredtime. frame when the CD-EDG was removed from service.

l One of the independent off-site sources is available on automatic and instantaneous transfer when normal auxiliary power is lost.

The second source is"a-69K,V transmission 7, e line which experience has shown can be manually connected to our plant busses in less.than.two' minutes.

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Further than this, we,.recently added aroth4r source of auxiliarypowersupplyoverthatrequiredkbbroperating

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SUPPLEMENT TO LER 78-037/OlT-1 J*

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Pcga 5 of 7 license.

This-power supply was,also available during the (j

' time of'this incident.

In the event the off-site transmission sources had been lost the US would have immediately known the AB-EDG did not start.

The AB-EDG could have been. checked out and the Starting Air. Pilot Valves opened-and the engine started in an estimated 5 minutes.

This is the first instance at the Cook Nuclear Plant

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where both_ diesel generators have been inadvertently made inoperable. ' Action. Item D in Technical Specification

?3.8.1.1 requires that'with two diesel generators inoperable at least' one of the inoperable diesel generators must be restoredzto operable status within two hours or be in at least. hot standby within the next six hours and in cold shutdown within.the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />.

During this inci-dent both diesel generators were inoperable for three hours which is within the 8 hour9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> time period specified by the

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Technical Specifications necessary to protect the health and safety of the public.

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,s SUPPLEMENT TO LER' 78-037/01T -.'

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Pago'6 of 7

'(E)

Corrective Action Taken to-Prevent Recurrence (1)

The entranceways to the EDG rooms have been painted.

orange for U-1-and blue for U-2.

On this blue or

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orange background, a large AB or CD has been painted in white.

This painting scheme makes it very obvious which EDG room is_being entered.

(2)

The entrances to all rooms containing. safety-related equipment have been marked by placing a sign-designat-ing the Unit and equipment in the room.'

This was completed October, 1978.

(3)

The components within the.EDG rooms have been clearly.

labeled.

(4)

PMI-21101 Equipment Control-Clearance Permit-System has been revised to require independent: verification of the tagging process by the Operations Department for all Technical Specification required equipment.

(5)

The'AEO_who closed and tagged'the wrong Starting Air s

Pilot valves was reprimanded in writing for his-error.

(6)

The Operations Superintendent met with the SOE and Operating Engineers for all four shifts to discuss this event and the severity of other recent events which have' occurred at the plant.

He also pointed out that-more severe disciplinary actions would be taken in the.-

future for careless operator errors.

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SUPPLEMENT TO LER 78-037/01T-1 Page 7 of 7 (7)

A key lock system has been installed on the COf

. isolation switch for each EDG room.

Except in unusual

- circumstances concurred in by the Operations Shift Supervisor, entry into such areas for the purpose of tagout and maintenance activities requires the presence of at least two independent _ entities [ worker (s) and either a security guard or a member of the dedicated fire watch crew), thereby lessening the probability of entering the wrong equipment room.

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