05000370/LER-2010-001

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LER-2010-001, Loose connection in a panel board serving a Solid State Protection System Train concurrent with redundant train maintenance could have prevented fulfillment of a safety function.
Docket Number
Event date:
Report date:
Reporting criterion: 10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident
Initial Reporting
3702010001R00 - NRC Website

BACKGROUND

The following information is provided to assist readers in understanding the event described in this LER. Applicable Energy Industry Identification [EIIS] system and component codes are enclosed within brackets. McGuire unique system and component identifiers are contained within parentheses.

The Solid State Protection System [JC](SSPS) consists of two trains (A and B), each consisting of four input channels (I, II, III, and IV), a logic train, and an output train. In response to SSPS input signals satisfying the applicable SSPS logic, slave relays in SSPS will actuate as needed a reactor trip and the following safety functions via an Engineered Safety Features Actuation System [JE](ESFAS) signal:

  • Phase A and Phase B Containment Isolation
  • . Containment Ventilation Isolation.
  • . . Steam Lifte Isolation.
  • Steam Dump Interlock
  • Turbine Generator Trip.. .
  • Automatic Switchover of Emergency Core Cooling Water to the Containment Sump
  • Containment Air Return and Hydrogen Skimmer Fans SSPS also provides Control Room annunciator, status light, and computer input signals which indicate the condition of bistable input signals, partial trip and full trip functions and the status of the various blocking, permissive and actuation functions.

Each SSPS Train is powered through fuses from the appropriate 120 VAC Vital I&C [EF](EPG) panel board. The EPG panel board supply for Channel 1 of SSPS Train A provides power for the A Train slave relays. The EPG panel board supply for Channel 4 of SSPS Train B provides the power for the B Train slave relays.

EVENT DESCRIPTION

On January 15, 2010 at approximately 1629 hours0.0189 days <br />0.453 hours <br />0.00269 weeks <br />6.198345e-4 months <br />, the Control Room received ten annunciators and bi-stable lights. These indications cycled on and off for a period. of approximately ten minutes and then remained off. During the period of time these indications were cycling on and off, no abnormal plant or equipment transients occurred. A failure investigation team was established to perform troubleshooting, evaluate plausible failure modes, and determine the failure cause.

On January 19, 2010 at approximately 1907 hours0.0221 days <br />0.53 hours <br />0.00315 weeks <br />7.256135e-4 months <br />, during troubleshooting related to the January 15, 2010 indications, the Control Room received twelve annunciators and bi-stable lights. These indications cycled on and off until approximately 1938 hours0.0224 days <br />0.538 hours <br />0.0032 weeks <br />7.37409e-4 months <br /> and then remained off. Ten of these annunciators and bi-stable lights were identical to the indications received on January 15, 2010. During the period of time these indications were cycling on and off, no abnormal plant or equipment transients occurred.

On January 20, 2010, based upon evidence gathered to date, including the fact that the annunciators and bi-stable lights were associated with circuits receiving power from Unit 2 EPG panel. board 2EKVA, the failure investigation team measured voltages and currents, performed thermography scans, and implemented visual inspections of panel board 2EKVA. Although these activities did not identify any abnormalities, they did identify a common bus bar connection on both the line side and the neutral side of panel board 2EKVA breaker8 3 and 4. 'A thorough'inspectioh of this connection was hampered since these breakers were energized and the connection was difficult to see.

On January 21, 2010, a critical activity plan was approved which provided for isolating power to Unit 2 EPG panel board 2EKVA breakers 3 and 4 to facilitate a thorough inspection of the common bus bar connection identified on January 20, 2010. As part of this inspection, this connection was to be checked for tightness.

On January 22, 2010 at 1312 hours0.0152 days <br />0.364 hours <br />0.00217 weeks <br />4.99216e-4 months <br />, while preparing to implement the critical activity plan, the Control Room received multiple annunciators and bi-stable lights similar to those received on January 15, 2010 and January 19, 2010.

These indications cycled on and off until approximately 1324 hours0.0153 days <br />0.368 hours <br />0.00219 weeks <br />5.03782e-4 months <br />. During the period of time these indications were cycling on and off, no abnormal plant or equipment transients occurred.

On January 22, 2010, while performing inspections of Unit 2 EPG panel board 2EKVA breakers 3 and 4 as per the critical activity plan, it was observed that the neutral connection under breaker 4, between the main bus bar and the bus connector piece for breakers 3 and 4 was significantly loose. The screw associated with this connection had backed out to the point that the bus bar connector piece was no longer making firm contact with the main bus bar.

On January 22, 2010, a modification was implemented which moved the electrical power cables previously connected to Unit 2 EPG panel board 2EKVA breakers 3 and 4 to previously spare breakers 24 and 9 on panel board 2EKVA.

On January 25, 2010, a reportability evaluation was initiated after investigation determined the intermittent annunciators and bi-stable indications received on January 15, 2010, January 19, 2010, and January 22, 2010 occurred concurrent with power to Channel 1 of Train A of Unit 2 SSPS cycling off and on as a result of the loose bus bar connection common to Unit 2 EPG panel board breakers 3 and 4.

On January 26, 2010, it was discovered that while powerto_Channel 1 of Train A of Unit 2 SSPS was cycled off,.none of the slave relays associated With Train A would .have been. capable of generating an ESFAS signal if needed; which would haVe prevented initiation of the Unit 2 Train A ESFAS related Safety functions.

On January 26, 2010, a review was performed to identify Unit 2 Train B equipment that was inoperable during the periods of time on January 15, 2010, January 19, 2010, and January 22, 2010 when power to Channel 1 of Train A of Unit 2 SSPS was cycling off and on. This review identified that, due to scheduled maintenance, the Unit 2 NS Train B safety function and the Unit 2 Train B safety injection DG actuation safety function were inoperable during the period of time on January 19, 2010 when power to Channel 1 of Train A of Unit 2 SSPS was cycling off and on (approximately 1907 hours0.0221 days <br />0.53 hours <br />0.00315 weeks <br />7.256135e-4 months <br /> to 1938 hours0.0224 days <br />0.538 hours <br />0.0032 weeks <br />7.37409e-4 months <br />). During this period of time, if SSPS had attempted to initiate the Unit 2 NS safety function and the Unit 2 safety injection DG actuation safety function while Channel 1 of Train A power was cycled off, fulfillment of these safety functions would have been delayed for a period of time that would not support the assumptions and conclusions of the applicable safety analyses. This represented a condition that could have prevented the fulfillment of a safety function needed to mitigate the consequences of an accident, which is reportable as per the requirements of 10 CFR 50.73(a)(2)(v)(D). Note, when power to Channel 1 cycled back on, SSPS contacts associated with the Unit 2 NS Train A safety function and the Unit 2 Train A safety injection DG actuation safety function would have latched in and these functions would have initiated. Upon latch in, these Train A safety functions would have continued as needed even if power to Channel 1 of Train A of Unit 2 SSPS had cycled back off.

CAUSAL FACTORS

The cause of the intermittent loss of power to Channel 1 of Train A of Unit 2 SSPS was a manufacturer fabrication deficiency. Specifically, a degraded connection under EPG panel board 2EKVA breaker 4, between the main bus bar and the breaker to bus bar connector for breakers 3 and 4, had developed an intermittent loose connection. This loose connection occurred when the connecting screw that holds the bus connector piece to the main bus bar backed out of the threaded hole in the main bus bar. Either the screw was not tightened properly initially or it was not designed/fabricated with sufficient locking mechanisms to prevent it from backing out over time.

This connection is inaccessible without removing the breakers and it is difficult to see. This screw loosened to the point where the electrical continuity of the bus bar connection was lost, thereby causing a loss of power to Channel 1 of Train A of Unit 2 SSPS. Upon losing electrical continuity, the increased resistance across the degraded bus bar connection caused temperature to increase, restoring the electrical continuity of the SSPS. Subsequent load fluctuations resulted in a decrease in resistance across the bus bar connection causing the temperature of the connection to drop causing the bus bar connection to lose electrical continuity, again causing a loss of power to Channel 1 of Train A of Unit 2 SSPS. This cyclic loss and restoration of electrical continuity at the bus bar connection for EPG panel board 2EKVA breaker 4 resulted in the intermittent loss of power to Channel 1 of Train A of Unit 2 SSPS.

Contributing Causes:

A contributing cause to this event was inadequate preventive maintenance on Unit 2 EPG panel board 2EKVA. A preventive maintenance (PM) procedure for the panel board provided for periodic inspection of the panel board for loose connections. However, the PM procedure did not provide specific inspection instructions for connections that were difficult to see, or not shown on the applicable vendor documents, as in the case of the degraded bus bar connection common to breakers 3 and 4 of EPG panel board 2EKVA.

Therefore, whenever the PM was performed on panel board 2EKVA, the connection common to breakers 3 and 4, which was difficult to see, was not inspected for a loose connection.

CORRECTIVE ACTIONS

Immediate:

1. Implemented a modification which moved the power supply for Channel 1 of Train A of Unit 2 SSPS from breaker 4 on Unit 2 EPG panel board 2EKVA to previously spare breaker 9 on that panel board. As part of this modification, the tightness of the breaker 9 bus bar connections was verified prior to placing the breaker back in service.

Subsequent:

1. The PM procedure which provides, for periodic inspection of the Unit 1 & 2 120VAC/125VDC Vital I&C panel boards was revised to ensure bus bar connections (including those bus bar connections that are inaccessible, difficult to see, or not shown on the applicable vendor documents) are adequately checked for loose connections.

Planned:

1.Starting with Unit 1 outage 1E0C20 (currently in progress)and the next Unit 2 outage (2E0C20), inspections of bus bar connections on the Unit 1 & 2 120VAC/125VDC Vital I&C panel boards for loose connections are planned. To date, 1E0C20 inspections of panel board bus bar connections have not identified any findings of significance.

2.Based upon results of the planned bus bar inspections of the Unit 1 & 2 120VAC/125VDC Vital I&C panel boards, modifications to replace these panel boards will be considered. If these modifications are implemented, bus bar connections in the new panel boards will be designed and fabricated to prevent loosening, or designed for better accessibility or viewing.

SAFETY ANALYSIS

safety injection DG actuation safety function while Channel 1 of Train A of Unit 2 SSPS power was cycled off, fulfillment of these safety functions would have been delayed for a period of time which would not support the assumptions and conclusions of the applicable safety analyses. Note, when NS Train A safety function and the Unit 2 Train A safety injection DG actuation safety function would have latched in and these functions would have initiated. Upon latch in, these Train A safety functions would have continued as needed even if power to Channel 1 of Train A of Unit 2 SSPS cycled back off. The longest period of time that power to Channel 1 of Train A of Unit 2 SSPS was cycled off between 1907 hours0.0221 days <br />0.53 hours <br />0.00315 weeks <br />7.256135e-4 months <br /> and 1938 hours0.0224 days <br />0.538 hours <br />0.0032 weeks <br />7.37409e-4 months <br /> on January 19, 2010 was approximately 2.25 minutes. This represents the longest duration of time on that date where fulfillment of the Unit 2 NS safety function and the'Unit 2 safety injection DG actuation safety function would not have occurred if needed.

A risk-informed approach was used to determine the significance associated with unavailability of Train A of Unit 2 SSPS and coincident unavailability of the Unit 2 NS Train B and the Unit 2 B Train DG. Conservatively, the unavailability duration used in this analysis was assumed to be 31 minutes (from approximately 1907 hours0.0221 days <br />0.53 hours <br />0.00315 weeks <br />7.256135e-4 months <br /> to 1938 hours0.0224 days <br />0.538 hours <br />0.0032 weeks <br />7.37409e-4 months <br /> on January 19, 2010). Due to the short duration of unavailability of Train A of Unit 2 SSPS, the Conditional Core Damage Probability (CCDP) and Conditional Large Early Release Probability (CLERP) associated with this event are negligible, based on being less than 1E-8 and 1E-9, respectively.

Given the above, this event is considered to be of no significance with respect to the health and safety of the public.

ADDITIONAL INFORMATION

To determine if a recurring or similar event exists, a search of the McGuire Problem Identification Process (PIP) database was conducted for a time period covering 5 years prior to the date of this event. Based on Duke's definition of a recurring event, similar significant event with the same cause code, no recurring events were identified.