05000312/LER-1987-001, :on 870117,fire Zone Detection & Suppression Sys Disabled for Grinding Work & Hourly Fire Watch Instituted Instead of Continuous Fire Watches.Caused by Failure to Follow Procedure

:on 870117,fire Zone Detection & Suppression Sys Disabled for Grinding Work & Hourly Fire Watch Instituted Instead of Continuous Fire Watches.Caused by Failure to Follow Procedure

ML20211B233
Person / Time
Site:	Rancho Seco
Issue date:	02/13/1987
From:	Colombo R, Julie Ward SACRAMENTO MUNICIPAL UTILITY DISTRICT
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM), NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
References
JEW-87-140, LER-87-001, LER-87-1, NUDOCS 8702190354
Download: ML20211B233 (5)

LER-1987-001, on 870117,fire Zone Detection & Suppression Sys Disabled for Grinding Work & Hourly Fire Watch Instituted Instead of Continuous Fire Watches.Caused by Failure to Follow Procedure

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(1)
3121987001R00 - NRC Website

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TIT LE (di llourly Rather Than Continuous Fire Watches EVENT DATE Ill LER NUMeER ts)

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LICENSEE CONTACT FOR TH1$ LER (12)

NAME TELEPaO*sF NUM9ER

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Ronald W. Colombo, Regulatory Compliance Superintendent

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During cold shutdown, at 6:35 p.rn. on 1/17/87, a fire zone's detection and suppression systems were disabled for grinding work, and an hourly fire watch was instituted. Due to a failure to follow procedures, the Nuclear Operations Fire Protection Coordinator (NOFPC) did not know that an adjacent fire area with a breached fire barrier was already under impaired fire detection at the time. Tech. Spec. 3.14.6 requires a continuous fire watch in a detection-l impaired fire area if any connected area is impaired. Upon discovery of the other impaired fire zone at 9:30 that evening, the Zone 75 fire watch was changed to continuous.

At 7:57 a.m. on 1/27/87, another fire detection system was disabled for welding work, requiring a continuous fire watch under Tech. Spec. 3.14.6.

The watch frequency in the zone had been changed from continuous to hourly the previous afternoon. However, since the previous evening's Shift Supervisor had failed to note the change in the Shif t Turnover Log, the continuous fire watch was not instituted, and the hourly watch was maintained until the fire detection system was reenabled at 2:09 p.m.

The public's health and safety were not affected.

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et GIRC Penn 300A UA. NUCLEA3 5'EGULATORY COMMIS$40N LICENSEE EVENT REPORT (LER) TEXT CONTINUATION ueROvEo Oui NO. 3no_cio.

EXPlRES; 8/31/88 LER NUMSER (4)

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Rancho Seco Nuclear Generating Station 9^"

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- w nn Plant oneratinR conditions before the event:

The plant has been shut down since December 26, 1985.

Status of structures. comoonents. or systems that were inocerable at the start of the event and that contributed to the' event:

On 1/17, the fire detection system for Fire Zone 81 was already impaired for Ignition source work in that zone. When the detection system in Fire Zone 75 was deactivated, it was not known that the system in adjacent Fire Zone 81 had also been deactivated. It was the failure to check for that impairment that resulted in the lack of continuous fire watch in Fire Zone 75.

On 1/27, the fire barrier between Fire Areas 78/1 and 78/2 was already breached, requiring an hourly fire watch in-both areas and a continuous fire watch once the zone fire detection system (which covers both areas) was I

impaired.

Dates and accroximate times of occurrences:

The failure to provide a continuous fire watch in Fire Zone 75 lasted from 6:35 p.m. to 9:30 p.m. on January 17,1987 (three hours total); the failure to provide a continuous fire watch in Fire Zone 78 lasted from 7:57 a.m. to 2:09 n

p.m. on January 27,1987 (six hours total).

The fintermediate and rootl causefs) of each comoonent or system failure or oersonnel error. If known:

l The intermediate cause in both cases was " operations error" On 1/17 the i

operations error was caused by a " procedure not used" because "not available or inconvenient for use" On 1/27 the operations error was caused by a " procedure less than adequate" in that AP.60 requires the posting and releasing of fire watches in the voluminous Shif t Management Log rather than the easier-to-us Fire Watch Log.

The failure mode fundesirable state of a system or comoonentl. mechanism l

(i. e. immediate causel and effect Ithe consecuence or malor concern resultina l

from the failurel of each failed comoonent. If known:

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l No components failed; the fire detection and/or CO2 suppression systems were properly impaired (disabled in accordance with plant procedures) by the plant workers to avoid spurious alarms and potential personnel suffocation.

The Enerzy Industry Identification System component function identifier and l

system name of each component or system referred to in the LER-l The tire detector system (IC,DET) and the CO2 system (KQ,GBM).

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groau 366A e U S GPO 1986 0 624 538 455

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macresansetA U.S. NUCLEA3 REIULATORY COMMISSION LICENSEE EVENT REPORT (LER) TEXT CONTINUATION ApenovEo oMe mo. mo_eio.

EXPtRES: 8/31/N FACILITV feassa (1)

DOCKET NUMBER (2)

LER NUMeER (4)

PAGE (3) i Rancho Seco Nuclear Generatin8 Station

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Unit 1 0l510l0l0l3l1l2 8l7 0l 0l1 Op 0l3 OF 0l4 venar emiew. ann-.< mice mmmm The method of discoverv of each comoonent or system failure or orocedural error (testing. Investigating. troubleshooting. tour. observationh The 1/17 procedural error was discovered by observation while the Nuclear Operations Fire Protection Coordinator's (NOFPC's) designee was entering the

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I impairment of the fire detection system into the LC011og. The 1/27 procedural error was discovered by routine observation by the NOFPC a few minutes before the need for the detection impairment was over.

For each oersonnel error. the licensee shall discuss:

• whether the error was a cognitive error (e.R.

failure to reconnize the actual l

olant condition. failure to realize which systems should be functioning. failure to recognize the true nature of the event) or a crocedural error:

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• any unusual characteristics of the work location (e.g.. heat. noise) that directiv contributed to the error: and

• the tvoe of oersonnel involved (i.e.

contractor oersonnel. utilltv-licensed ooerator. utility non-licensed operator. other utility nersonnel).

On 1/17, the cause was a procedural error (failure to follow the procedural requirement to check adjacent fire zones for impairment) by a contractor. On 1/27, the cause was a cognitive error (mistaken summarization of fire watch requirements at shift turnover) by a utility-licensed operator.

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An assessment of the safety consecuences and imolications of the event Ie.g.

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imolication of the event if it occurred during other olant conditions. esoecially l

during oower ooerations -- or why it could not have haonened durinz Dower coerationsl: this includes the availability of other systems or comoonents that can oerform the same function as the comoonents or systems that failed during the event for why there were no safety imolications. referring to the USAR analysisl:

Neither of the events had any immediate safety consequences, since no fires occurred during the short periods when an hourly fire watch was in effect rather than the required continuous watch. Neither would there have been any consequences if a design basis fire had occurred during these events, even if the plant had been in power operation at the time. The adjacent fire zones involved on 1/17 (75 and 81) both have electrical distribution equipment and circuits needed for safe shutdown, but only for Train B -- Train A would not have been involved in any postulated fire in either or both of the zones. The adjacent fire areas involved on 1/27 (78/1 and 78/2) contain safe-shutdown-related electrical distribution equipment and circuits, but only for Train A --

Train B would not have been affected by any postulated fire involving both fire areas in Zone 78.

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• LICENEEE EVENT REPORT (LER) TEXT CONTINUATION mRovEo oMe No. 3:so-oio.

EXPtRES: $/31/88 PACILATV seAaSE 131 DOCKET NUMSER (2)

LER NUMSER (4)

PAGd (3)

Rancho Seco Nuclear Generating Station i

Unit 1 0151010 lo l 311 l 2 81 7 010l1 0 10 01 4 0F 0l4 men.s sm waner..m4wnn A descriotion of any corrective actions olanned as a result of the event.

Including those to reduce the orobability of a similar event occurring in the future:

l The immediate corrective action on 1/17 was to institute the required continuous fire watch, and on 1/27 to restart the fire detection system that had been impaired.

Actions to prevent recurrence focus on their different causes. The individual who made the erroneous recommendation of an hourly fire watch was counselled to resist pressure to make quick decisions in the field when the required data are in the NOFPC office. Because the 1/17 occurrence was similar to a previously reported event (ref. LER 86-08), the measures to prevent further recurrence will also include modification of Administrative Procedure AP.60. Under the revised procedure, the NOFPC or his designee'will be specifically directed to return to the NOFPC office and check the Log before issuing a fire watch recommendation. The fire prevention staff will be trained in the modified procedure.

The Shift Supervisor's cognitive error will be prevented in the future by another modification to AP.60. Under the revised procedure, fire watch changes will be recorded in the Control Room's original Fire Watch Log for ease of reference.

Reference to any Drevious similar events at the same olant that are known to the licensec:

i The District has reported fire watch problems in LERs 86-04, 86-08, 86-31, and 86-32. LERs 86-04 and 86-32 describe missed zones in the Security Department's hourly fire watch circuit, and 86-31 resulted from a misunderstood telephone instruction from the Fire Protection Coordinator to the Shift Supervisor. None of the measures to prevent recurrence of these events apply to this LER. LER 86-08 reported a similar event to that of 1/17, with training in AP.60 as the preventive measure.

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' SACRAMENTO MUNICIPAL UTILITY DISTRICT C P. O. Box 15839, Sacramento CA 95852=1830, (916) 452 '3211 AN ELECTRIC SYSTEM SERVING THE HEART OF CALIFOHNIA l

JEW 87-140 February 13, 1987 J. B. Martin, Regional Administrator Region V Office of Investigation and Enforcement Attn Document Control Desk U.S. Nuclear Regulatory Commission Washington, D.C.

20555 Docket No. 50-312 Rancho Seco Nuclear Generating Station Unit *1 License No. DPR-54 LICENSEE EVENT REPORT 87-01, HOURLY RATHER THAN CONTINUOUS FIRE WATCHES

Dear Mr. Martin:

In accordance with the requirements of 10 CFR Part 50.73(a)(2)(1)(B), the Sacramento Municipal Utitlity District hereby submits Licensee Event Report Number 87-01.

If there are any questions concerning this report, please contact Mr. Ron W.

Colombo at the Rancho Seco Nuclear Generating Station.

Sincerely, Ca John E. Ward Deputy General Manager, Nuclear Attachment cc: Region V (2)

INPO

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RANCHO SECO NUCLEAR GENERATING STATION L 14440 Twin Cities Road, Herald, CA 95638-9799;(209) 333-2935 J