न्यूक्लियर पॉवर कॉरपोरेशन ऑफ इंडिया लिमिटेड

Nuclear Power Corporation of India Limited

(भारत सरकार का उद्यम A Govt. of India Enterprise)
नरौरा परमाणु विद्युत कें द्र Narora Atomic Power Station

HUMAN PERFORMANCE ENHANCEMENT SYSTEM (HPES)

INVESTIGATION REPORT

Reference: 1. RCA Report No. RCA/NAPS-1/2020-21/01 Dated 17.01.2021

2. Event Report Number. ER/NAPS-1/20-21/20 Dated 09.01.2021

3. Others -

EXECUTIVE SUMMARY

(To be filled after completing Behavioral Factor Analysis, Causal factor Analysis &
Situational Analysis in subsequent pages)

1. Unit : NAPS-1

2. Event Date : 06.01.2021

3. Event Description :

NAPS-1 was operating at 218 MWe and NAPS-2 was under BSD on 06.01.2021. 220 kV
switchyard Bus-C was isolated and all the 220 kV feeders (GT-1, SUT-1, L-1, L3, L-4, SUT-
2, L-5 through transfer CB-10) were connected to Bus-B. 220 KV L-2 was under permit.
Bus-C differential protection scheme testing for GT-2 was under progress. At 12:26:20
Bus Bar differential Protection got actuated for Bus-B & Bus-C simultaneously, resulting
in tripping of all the feeders connected to Bus-B. Tripping of NAPS-1 SUT caused AUTO
Transfer and CB-17 closed as per scheme. Unit came on house load through CB-16 but
turbine tripped on ‘Over Speed’ resulting in Class-IV power failure in NAPS-1. Reactor
tripped on ‘No PCP Running’. Tripping of NAPS-2 SUT caused Class-IV failure in NAPS-2
also

4. Event Consequences: Outage of operating unit-1

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5. Is this a Report Event: No (Unit outage of actuation of bus bar differential protection on
30.04.2011, 28.08.2011 and 30.08.2016 but reason of actuation were different.

6. Human Performance Problems

Description of Is it a
Item Consequences
Inappropriate Action (S) Report?
Transfer breaker CB-10 was in service for No Effect of CB-10 on bus
220kV Line-5 as overhauling job on DS-42 bar differential during
(Bus-C side DS for Line-5) was under testing not visualized
1. progress & expected to be completed by
11-12 Hrs.

(Procedure non adherence)

Before injecting current second time in B- No. Injected test current was
phase of Bus-C differential relay to check more than trip setting
alarm relay, technician might have rotated which caused actuation
knob of Sverker-750 test kit in clockwise of 220kV bus differential
direction instead of anti-clockwise protection.
2. direction to reduce current to zero which
remained un-noticed.

(Self-checking / verification process not

used)

7. Causal Factors (Internal/External Affecting Human Performance:

Causal Factors (Internal) that led

Sr. No. Is it a repeat one? Consequences
to the inappropriate actions
1. Self -checking not used or No Effect of CB-10 on
ineffectively applied. (0201) bus bar differential
2 Violation of policies / rules / No during testing not
procedures. (0218) visualized
3. Required procedures, drawings or No Injected test current
other references not used. (0203) was more than trip
setting which caused
actuation of 220kV
bus differential
protection.

Causal Factors (External) that led to

Sr. No. Is it a repeat one? Consequences
the inappropriate actions
1. - - -

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8. Chronological Description of Event.

Person involved in Bus-C differential protection scheme testing for GT-2 and Line-2 ON
06.01.2021 were inter-reviewed and following information were collected.

(i) Transfer breaker CB-10 was in service for 220kV Line-5 as overhauling job on DS-42 (Bus-C
side DS for Line-5) was under progress & expected to be completed by 11-12 Hrs.
(ii) Bus-C differential protection for GT-2, Line-2 and Bus coupler was planned for the
06/01/2021.
(iii) CB-10 is required to extended Bus-A to Bus-C for bus differential protection scheme
testing of as per procedure. As CB-10 was used for 220 kV line-5. Hence engineer decided
to check the operation of alarm relay of Bus-C differential protection scheme.
(iv) Bus-B CT switching relays for 220kV element connected to Bus-B were in operated
condition i.e Line-1, Line-3, Line-4, Line-5, SUT-1, and SUT-2 & GT-1.
(v) Bus-C side CT switching relays for all 220kV elements were in reset condition.
(vi) Link of TB 211, 212, 213, 214 in panel B1-8B for CT secondary wires of GT-2 dropped.
(vii) Link of TB-419, 420 and TB-417, 418 in panel B1-8B for 250VDC supply to Bus-B and Bus-C
side CT switching relay of GT-2 dropped.
(viii) Bus-C side CT switching relay for GT-2 operated manually and Bus-B side ensured in reset
condition.
(ix) Control engineer informed regarding testing of Bus-C differential protection for GT-2 and
communicated that “WAN-357: Bus-B / Bus-C differential blocked” alarm will appear
during test.
(x) Test stared around 12:00Hrs on 06.01.2021. Current injected for R-Phase of GT-2 and
appearance of alarm WAN-357 conformed from control room. Similarity it was done to Y-
Phase and B-Phase but “WAN-357: Bus-B / Bus-C differential blocked” alarm could not be
confirmed from control room for B-phase.
(xi) RED led appeared at panel B1-8B for Bus-C differential protection blocked when current
injected in B-Phase however resetting was done prior to confirmation from control room.
(xii) Alarm checking with current injection was done between 12:00 Hrs to 12:10 Hrs.
(xiii) As alarm (WAN: 357) could not be confirmed by engineer from control room. It was
decided to repeat the alarm checking for B-Phase again.
(xiv) Current injection in B-Phase of GT-2 was done at and 12:20Hrs and bus-B differential
protection and Bus-C differential actuated simultaneously. It was also noticed that
injected current was more than 1500mA i.e. out of scale in analog multi-meter.
(xv) before injecting current second time in B-phase of Bus-C differential relay to check alarm
relay, technician might have rotated knob of Sverker-750 test kit in clockwise direction
instead of anti-clockwise direction to reduce current to zero which remained un-noticed.

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(xvi) Current adjustment knob of test kit was on higher side i.e. instead of zero side when test
kit was switched ON for current injection. This led to current injection more than trip
setting of differential relay.
(xvii) When current injection by pressing "ON key" of test kit was switched ON, B-phase of Bus-
C differential relay (Flag of B-phase designated as T in scheme) and final trip alarm relay
(designated as U in scheme) of Bus-C differential relay (F1B:131) and Final trip relay alarm
relay (F7B:143) of Bus-B differential relay operated.

9. Summary of Causes.

Work Practices:-

(i) Procedure non Adherence:-

Overhauling of DS-42 (Bus-C side DS) of transfer breaker was under progress and
expected to completed on 06.01.2021. As CB-10 was used for 220kV Line-5 and
connected to Bus-B. Hence it was decided to check alarm “Bus-B / Bus-C
differential protection Blocked” without assessing effect all this change from
procedure.

(ii) Self -checking not used or ineffectively applied:-

Injected current during the exceeded trip setting of differential protection relay.

10. Proposed Recommendations.

Refresher training to be imparted to EMU group for ensuring use of Error Prevention Tools

11. Proposed Corrective Actions.

Refresher training to operation and maintenance personal on use of Error Prevention

Tools shall be ensured at regular interval.

Vivek Kumar H.S.Singh

Member Secretary, SRCA committee Acting Chair Person, SRCA committee

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