05000316/LER-1993-001, :on 930202,discovered That Fire Door to Pressurizer Heater Transformer Room Standing Open W/Safety Pins Installed in Door Tracks.Caused by Personnel Error.Pins Pulled & Fire Door Closed
| ML17331A078 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 03/04/1993 |
| From: | Blind A, Joel Wiebe INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LER-93-001, LER-93-1, NUDOCS 9303090565 | |
| Download: ML17331A078 (6) | |
| Event date: | |
|---|---|
| Report date: | |
| 3161993001R00 - NRC Website | |
text
ACCEI.ERA D DOCUMENT DIST UTION SYSTEM REGULA RY INFORMATION DISTRIBUTI SYSTEM (RIDS) l
SUBJECT:
LER 93-001-00:on 930202,discovered that TS compensatory action not met due to personnel error. Safety pins pulled fire door was closed.W/930304 ltr.
/
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IE22T COPIES RECEIVED:LTR ENCL
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TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.
D NOTES:
ACCESSION NBR:9303090565 DOC.DATE: 93/03/04 NOTARIZED: NO
'OCKET FACIL':50-316 Donald C.
Cook Nuclear Power Plant, Unit 2, Indiana M
05000316 AUTH.NAME "AUTHOR AFFILIATION WIEBE,J.S.
Indiana Michigan Power Co. (formerly Indiana
& Michigan Ele BLIND,A.A.
Indiana Michigan Power Co. (formerly Indiana
& Michigan Ele R RECIP.NAME RECIPIENT AFFILIATION I
RECIPIENT ID CODE/NAME PD3-1 LA DEANgW INTERNAL: ACNW AEOD/DSP/TPAB NRR/DE/EELB NRR/DORS/OEAB NRR/DRCH/HICB NRR/DRIL/RPEB
~~~S SPLB RGN3 FILE 01'XTERNAL:
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PLEASE HELP US TO REDUCE WASTE! CONTACI'HE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 504-2065) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEEDI D
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LTTR 30 ENCL 30
Indiana Michigan~
Power Company~
Cook Nuclear Plant One Cook Place Bridgrnan, Ml 49106 616 465 5901 March '4, 1993 tNKlMHA NlCRl64K POMfER United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-74 Docket No. 50-316 Document Control Manager:
In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ort S stem following report is being submitted:
93-001-00 Sincerely, the A. A. Blind Plant Manager
/sb Attachment CI A. B. Davis, Region III E. E.,Fitzpatrick P.
A. Barrett R. F. Kroeger B. Walters Ft.
Wayne NRC Resident Inspector W.
M. Dean NRC J.
G. Keppler M. R. Padgett G. Charnoff, Esq.
D. Hahn INPO S. J.
Brewer B. A. Svensson 9303090565 930304 PDR ADOCK 050003l6 8
NAG FORM 366 (6001 UX. NUCLEAR REGULATORYCOMMISSION UCENSEE EVENT REPORT (LER)
Donald C.
Cook Nuclear Plant APPROVED OMS NO. 31500104 EXPIRES/ 4I30/02 ESTIMATED SUADEN PER
RESPONSE
TO COMPLY WTH THIS INFORMATION COLLECTION REOUESTt 504) HAS. FORWARD COMMENTS REGARDING SUADEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENTSRANCH (F430). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON. OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT 131500104).
OFFICE OF MANAGEMENTAND BUDGET,WASHINGTON.DC20503.
PA 6
DOCKET NUMSER (2) 0 5
0 0
0 3
1 6
oF 0
4 Technical Specification Compensatory Action not Met Due to Personnel Error After the Blockin 0 en of a Fire Door EVENT DATE(5)
LER NUMSER (6)
RE POAT DATE (7l OTHER FACILITIES INVOI.VEDIS)
MONTH DAY YEAR YEAR SEOVENT/AL NVMSER MONTH Nt/MS6 tt OAY YEAR FAC/LITYNAMES DOCKET NUMbER(SI 0
5 0
0 0
0 202 939 3
0 0
1 0 003 0
4 9
3 0
5 0
0 0
OPERATING MODE ($ )
POWER LEYEL 1
0 0 yjg@l4'0.402(lt) 20.40541(1) (II 20405(e) (IIIIII 20.406 I el
(I)lill) 20.405 Ie )(1 I(4) 20.405 Ie) 11) lel 20.406(c) 50M(e) (I) 50.36(c) (2) 60.734((2)(II 50.73(el(2) (6) 50.73 4)(2) OilI 50.73lel(2)(itl lb.734 )(2 I(el 50 73( ~l(2llrii) 60.73(el(2)4illl(A) 50.73(el(21(rll/l(SI 50.73 4((2)hl 0 THE RLOUIREMENTS OF 10 CFR (I: ICntce ont or mort or tnt for/ornnf/ I'11 THIS REPORT IS SUSMITTEO PURSUANT T 73.7104) 73.7)(c)
OTHER ISotc//yin Aottrtct oe/erron/fin Test. NRc Form 3664/
NAME LICENSEE CONTACT FOR THIS LER (12)
Joel S. Wiebe Safety and Assessment Superintendent AREA CODE TEI.EPHONE NUMSER 6
1 6
4 6
5 - 5 9 0 1
COMPLETE ONE LINE FOR EACH COMPONENT FAILURE OESCRISEO IN THIS REPORT (13)
CAUSE
SYSTEM COMPONFNT MANUFAC.
TURER EPORTASLE TO NPRDS ma~W
CAUSE
SYSTEM COMPONENT MANUFAC..
TUAER EPORTASL TO NPADS ~84%
j$'A$riWi SUPPLEMENTAL REPORT EXPECTED (14l YES Iifytr, cornO/ttt EXPECTED SUdetlSSIOII DATE/
X N'SSTRACT ILirn/Ito Ic/)0 eoectt, I.t.. eooroeirnettly flftttnt/ncrteotct tyotrrrrtttn /met/ 116)
EXPECTED SUb MISS ION DATE Ilbl MONTH OAY YEAR On February 2, 1993, with Unit, 2 in Mode 1 (Power Operation),
at approximately 1935 hours0.0224 days <br />0.538 hours <br />0.0032 weeks <br />7.362675e-4 months <br /> an employee noted that the fire door to the Pressurizer Heater Transformer Room was standing open with the safety pins installed in the door tracks.
This condition makes the fire door inoperable.
It was verified that there was no one in the area and the Pressurizer Heater Transformer Room was not being toured by fire watch personnel.
The last time that the fire door was known to be closed was at 1422 hours0.0165 days <br />0.395 hours <br />0.00235 weeks <br />5.41071e-4 months <br /> on February 2,
1993, at which time the Pressurizer Heater Transformer Room was removed from a fire watch tour after some work was completed in the area.
The exact time when the fire door was left open could not be determined, therefore it must be assumed that the door could have been inoperable for approximately 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> with no" compensatory measures in place.
For immediate corrective action, the safety pins were pulled and the fire door was closed.
A technical evaluation of the condition concluded that defense-in-depth fire protection adequately protected the fire safety of the plant.
NRC 5toot 365 (6651(649)
UA. NUCLEAR REGULATOAYCOMMISSION LICENSEE EVENT REPORT ILER)
TEXT CONTINUATION APPROYEO 0MB NO.S)600(06 EXPIRES: 6/30/93 ESTIMATED BUAOEN PER AESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REOUESTs 50.0 HRS, FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE AECORDS ANO REPORTS MANAGEMENTBRANCH (P430), U S. NUCLEAR AEGULATORY COMMISSION, WASHINGTON. DC 30555, AND TO THE PAPERWORK AEDUCTION PAO/ECT (31604)OS). OFFICE OF MANAGEMENTANO BUDGET, WASHINGTON,OC 30503.
FACILITYNAME (11 DOCKET NUMBER (3)
YEAR LER NUMBER 15)
SEOVENTIAL SS VM6 E R REVISION SSVM ER PAGE LS)
Donald C.
Cook Nuclear Plant TEXT /// mdss ssssss
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o '31 693 001 00 02 QF 0 4
Conditions Prior to Occurrence Unit 2 (U-2)
- - in Mode 1 (Power Operation)
Descri tion of Event On February 2,
1993, with Unit 2 in Mode 1 (Power Operation),
at approximately 1935 hours0.0224 days <br />0.538 hours <br />0.0032 weeks <br />7.362675e-4 months <br /> an employee noted that fire door (EIIS/NF-DR) 2-DR-AUX314-244 to the Pressurizer Heater Transformer Room was standing open with the safety pins installed in the door tracks.
This fire door is a roll up type door which becomes inoperable when the safety pins installed.
It was verified that there was no one in the area and the Pressurizer Heater Transformer Room was not being toured by fire watch personnel.
Investigation of the event revealed that fire watch personnel had been in the Pressurizer Heater Transformer Room earlier that day in support of fire detector (EIIS/IC) testing.
The work was completed and the fire watch was released at approximately 1422 hours0.0165 days <br />0.395 hours <br />0.00235 weeks <br />5.41071e-4 months <br />.
At that time the safety pins were removed and the door was placed in the closed position.
This is the last time that the fire door was known to be closed.
The exact time when the fire door was left open cannot be determined, therefore it must be assumed that the door could have been inoperable for approximately 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> (1423 hrs.
to 1935 hrs.) with no compensatory measures in place.
Fire door 2-DR-AUX314-244 is located in the wall which separates the Pressurizer Heater Transformer Room (Fire Zone 20) from the Turbine Building (EIIS/NM) 591'levation (Fire Zone 85).
The Pressurizer Heater Transformer Room is equipped with ionization type fire detectors which were operable during the time in question.
The Turbine Building 591'levation is equipped with a wet pipe sprinkler system (EIIS/KP-SRNK) that was operable during the time in question.
Fire door 2-DR-AUX314-244 is the only access and egress for fire zone 20.
This door is mounted on the inside of the door opening with the manual opening mechanism also on the inside.
The door is equipped with safety pins that, in the event, of a fire, would hold the door open at 5 feet above the floor.
This would allow an injured person, who cannot manually operate the door, a way to exit while also reducing the overall size of the opening between fire zones.
NRC FOAMSMA (609)
US. NUCLEAR REGULATORYCOMMISSION LICENSEE EVENT REPORT ILER)
TEXT CONTINUATION APPROVED OMB NO.3(500104 EXPIRES: t)30/92
'STIMATED BURDEN PER
RESPONSE
TO COMPLY WTH THIS INFORMATION COLLECTION AEOUEST: 500 HAS. FORWARD COMMENTS REGARDING BURDEN ESTIMATETO THE RECORDS AND REPORTS MANAGEMENTBRANCH IP430), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, ANO TO THE PAPERWORK REDUCTION PROJECT (3150010t>, OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON,DC 20503.
FACILITYNAME (1I DOCKET NUMBER (2)
VEAA LER NUMBER IS) v SSOUENTIAL.p<v NEvrSK)N NUMOSN
'<4 NUM oil PAGE IS)
Donald C.
Cook Nuclear Plant TEXTfffmart tatto IIrfftittf,utt trfrfro'orrtfIYRC Form 36M'tl 117) o s
o o
o 31 693 001 00 0
30F 0
4
Cause of Event
The cause of this event cannot be determined with any degree of certainty.
The individual responsible for leaving the fire door open is unknown.
Without the ability to question the responsible individual it was not possible to determine why the fire door was=left in an inoperable configuration or how long it existed under this condition, a
sis of Event This report is being submitted in accordance with 10CFR50.73, paragraph (a)(2)(i)(B) as a condition prohibited'y Technical Specifications.
A technical evaluation of the condition concluded that a fire would not propagate between the Fire Zone 20 (Pressurizer Heater Transformer Room) and Fire Zone 85 (591'lev. Turbine Bldg.). which are on either side of the inoperable fire door.
The following reasons were noted:
The combustible loading within Fire Zone 20 has an equivalent fire severity of less than two minutes.
The combustible loading within Fire Zone 85 has an equivalent fire severity of less than five minutes.
These combustible loadings are considered very low.
2.
Any fire in Fire Zone 20 or 85 would be detected by the automatic ionization type fire detectors or automatic wet pipe sprinklers while the fire was small.
3 A fire"within Fire Zone 85 would be effectively extinguished by the automatic wet pipe sprinkler system.
4.
There are no significant ignition sources or fixed fire exposure hazards to threaten the degraded fire door.
This condition makes propagation of fire through this opening extremely unlikely.
5.
Manual fire fighting equipment is readily available for use by the fire brigade.
6.
The subject fire door would perform as designed provided the -door was manually shut.
It is concluded that the defense-in-depth fire protection provided in these areas adequately protected the fire safety of the plant.
NRC Form 35SA (639)
NRC FORM SBBA IB40)
FACILITYNAME III ILB.NUCLEAR h EQULATORY CO)rerNBBION LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION DOCKET NUMBER )2)
APPROVED OMB NO. S)504))04 EXPIRES: 4)SO/02 ESTIMATED BURDEN PER
RESPONSE
TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50'> HRS. FORWARD COMMENTS REQARDINQ BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENTBRANCH IP420). U.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON. DC 20555, ANDTO THE PAPERWORK REDUCTION PROJECT (21504)104). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON,DC 20503.
PAGE IS)
LER NUMBER (5)
YEAR SEQUErrYIAL NUMBER II5vre ION rrvv ee Donald C.
Cook Nuclear Plant TEXT Ilfmere 4OeOP re reeerred.
rree afdeOnV HRC FOVm 25542) IIT) o so o o 31 693 001 00 04 oF 0 4
Corrective Actions
Upon discovering that fire door 2-DR-AUX314-244 was in an inoperable configuration, the safety pins were removed from the door tracks and the door was closed.
As previously stated, the cause of the event could not be determined.
Without knowing.why the individual left the door in an inoperable configuration, the effectiveness of any new preventive measures becomes suspect.
All reasonable preventive measures have already been taken to ensure-that fire door 2-DR-AUX314-244 is left in an acceptable configuration upon exi.ting the Pressurizer Heater Transformer Room.
These measures include attaching chains to the safety pins that block the door area requiring that personnel duck under the chains if the pins are not removed and the posting of reminder signs in prominent locations to remind personnel to'emove the safety pins from the door tracks upon leaving the ar'ea.
The last occurrence.of a similar event was on March 3, 1986.
While plant management does not take this occurrence lightly, the amount of time lapsed between these events would not indicate the existence of an adverse trend.
Plant Management is aware of the value of "Self Checking" which may have been able to prevent, the occurrence of this event, and has recently begun training all plant personnel in the methods of "Self Checking".
Additionally, in order to heighten personnel awareness of the significance of events of this nature, an article will be placed in an internal plant publication.
Failed Com onents Identified None
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