05000316/LER-1995-001, :on 950106,Unit 2 Fire Detection Sys Was Made Inoperable W/O Compensated Action Due to Personnel Error. Restored Switch to on Position & Completed Test

:on 950106,Unit 2 Fire Detection Sys Was Made Inoperable W/O Compensated Action Due to Personnel Error. Restored Switch to on Position & Completed Test

ML17332A587
Person / Time
Site:	Cook
Issue date:	02/20/1995
From:	Beilman T, Blind A INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-95-001, LER-95-1, NUDOCS 9503010362
Download: ML17332A587 (5)

LER-1995-001, on 950106,Unit 2 Fire Detection Sys Was Made Inoperable W/O Compensated Action Due to Personnel Error. Restored Switch to on Position & Completed Test

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(iv), System Actuation 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(i) 10 CFR 50.73(a)(2)(ii) 10 CFR 50.73(a)(2)(iii) 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability 10 CFR 50.73(a)(2)(x) 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
3161995001R00 - NRC Website

text

H.j.MME' ACCELERATED RIDS PROCESSING I

REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9503010362 DOC.DATE: 95/02/20 NOTARIZED: NO DOCKET FACIL:50-316 Donald C.

Cook Nuclear Power Plant, Unit 2, Indiana M

05000316 AUTH.NAME AUTHOR AFFILIATION BEILMAN,T.P.

Indiana Michigan Power Co.

(formerly Indiana

& Michigan Ele F

BLIND,A.A.

Indiana Michigan Power Co.

(formerly Indiana

& Michigan Ele RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 95-001-00:on 950106,Unit 2 fir detection sys was made inoperable w/o compensated action due to personnel error.

Restored switch to "on" position

& completed test.

DISTRIBUTION CODE:

IE22T COPIES RECEIVED:LTR 2 ENCL 2 SIZE:

TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES C

F RECIPIENT ID CODE/NAME PD3-1 PD INTERNAL: AEOD/ESRD/RAB

~FILE CENTERS 02 NRR/DE/EELB NRR/DISP/PIPB NRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DSSA/SPLB RES/DSIR/EIB EXTERNAL: L ST LOBBY WARD NOAC MURPHY,G.A NRC PDR COPIES LTTR ENCL 1

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RECIPIENT ID CODE/NAME HICKMAN,J AEOD/SPD/RRAB NRR/DE/ECGB NRR/DE/EMEB NRR/DOPS/OECB NRR/DRCH/HICB NRR/DRSS/PRPB NRR/DSSA/SRXB RGN3 FILE 01'ITCO BRYCE,J H

NOAC POORE,W.

NUDOCS FULL TXT COPIES LTTR ENCL 1

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1 NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE! CONTACTTHE DOCUMENTCONTROL DESK, ROOM Pl-37 (EXT. 504-2083 ) TO ELIMINATEYOUR NA'ME FROM DISTRIBUTIONLISTS FOR DOCUMENTS YOU DON'T NEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED:

LTTR 26 ENCL 26

Indiana Michigan Power Company Cook Nuclear Plant One Cook Place Bridgrnan, Ml 49106 616 465 5901 February 20, 1995 INDIANA NICHIGAN POWER 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 the following report is being submitted:

95-001-00 Sincerely, A. A. Blind Plant Manager

/mr Attachment lj c:

J.

B. Martin, Region III E.

E. Fitzpatrick P. A. Barrett R. F. Kroeger M. A. Bailey Ft.

Wayne NRC Resident Inspector J.

B. Hickman NRC J.

R. Padgett G. Charnoff, Esq.

D. Hahn INPO S. J.

Brewer 9503010362 950220 PDR ADOCK 05000316 S

PDR

NRC FORM 366 IS 92i

. NUCLEAR REGULATORY COMMISSION LlCENSEE EVENT REPORT (LER)

(See reverSe fOr required number Of digitS/CharaCterS far eaCh blOCk)

PROVED BY OMB NO. 315~104 EXP (RES 5/31/95 ESTIMATED BURDEN PER

RESPONSE

O COMPLY VENT THIS INFQRMAtlON COLLECTCN 4EOUEST:

'".0 "PS FO~~

COMMENTS REGARtXNG BUIIEN ESTIMATE TQ THE INFORMADQN ANO RECORDS MANAGEMENTBRANCH (MNBB TTIeL U.S. NUCLEA REGULATORY CQMMISSCN WASHINGTON OC 20666~I. MO TO THE PAPERWORK REDUCTION PROrECT Oidooicek OFFCE OF MANAGEMENTANO BUDGET. WASHINGTON. CC 20600.

FACIUTYNAMElil DONALD C.

COOK NUCLEAR POWER PLANT UNIT 2 DOCKET NUMBER IT) 0S000 316 PAGE ITI 10F 3 UNIT 2 FIRE DETECTION SYSTEM MADE 'INOPERABLE WITHOUT COMPENSATORY ACTION DUE TO PERSONNEL ERROR.

EVENT DATE 5 MONTH DAY LER NUMBER 6 SEOUENtiAL NUMBER REVISION NUMBER I REPORT NUMBER 7 OAY YEAR OTHER FACILITIES INVOLVED(8 OQCKET NUMBER FACIUTYNAME 05000 01 06 95 95 001 00 02 20 95 FACIlflvNAME DOCKET NUMBER 05000 OPERATING MODE (9)

POWER LEVEL (10) 100K 20.405(c) 50.73(a) (2) (iv) 50.73(a) (2) (v) 20A02(b) 20 405(a)(1)(i) 73.71(bl 73.71(cl 50.36(c) (1)

OTHER 50.36(c) (2) 50.73(a) (2) (i) 50.73(a) (2) (ii) 50.73(a) (2)(iii) 50.73(a) (2) (vii) 50.73(a) (2l(viii)(A) 50.73(al(2) (viii)(B) 50.73(a) (2) (x) 20A05(a)(1) (ii) 20.405(a) (1) (iii) 20.405(a) (1) (iv) 20.405(a) (1l(vl iseeeeY ul AeeINCI de~ end ~ TeII, NRC Form 066AI LICENSEE CONTACT FOR THIS LER 12 TELEPHONE NUMBER iincwoe Alee Coeel THIS REPORT IS SUBMITTED PURSUANT TO THE REOUIREMENTS OF 10 CFR i: ICheck one or morel 11

'"T.

P B

INTENANCE SUPERINTENDENT 616 466-2601 COMPLETE ONE UNE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13

CAUSE

SYSTEM REPORTABLE To Npres REPORTABLE COMPONENT MANUFACTURER TO NPROS SUPPLEMENTAL REPORT EXPECTED 14 YES FI Yee. camreeie EXPECTED SUBL0SSION DATE)

ABsTRAOT (Limitto 1400 spaces.

i.e. ~ approximately 15 single-spaced typewntten knes)

(16)

~ECTED SUBMISSION DATE (15)

DAY YEAR On January 6, 1995 at 1112 hours0.0129 days <br />0.309 hours <br />0.00184 weeks <br />4.23116e-4 months <br /> it was discovered that the Unit 2 fire detection monitor panel switch (EZIS/ZC-HS) had been placed in the "off" position during the performance of a surveillance.

Zn the "off" position, visual and audible alarms associated with the Unit 2 fire detection zones will not alarm in the Control Room.

Zt was determined that the switch had been in the "off" position for approximately three hours, during which time all Unit 2 fire detection was inoperable without the appropriate compensatory measures being taken.

On January 26, 1995 it was determined that this event was reportable under 10CFR50.73(a)

(2) (i) (B), as operation prohibited by Technical Specifications.

The event is attributed to personnel error.

The switch was left in the "off" position in violation of the procedure being used to perform the surveillance.

If a fire had occurred during the period when the fixe detection system was inoperable, a "Fire System Actuation" or "C02 Header Pressurized" alarm would still have annunciated in the Control Room for the areas provided with fire suppression capabilities, alerting the Control Room to a fire in the monitored areas.

Routine security patrols and operator tours were also ongoing for areas without a fire suppression system.

Zn addition, multiple Unit 2 fire detection zones were being toured as a result of other fire protection concerns.

Based on this, the event did not represent a significant safety hazard and at no time was the health of safety of the public placed in jeopardy.

S4C FC4M $66 I6 921

HAC fORM SSSA [64(SI U.S. NUCLEAR AEGULATOAYCOMMISSION APPROVEO OM6 HO. 21600104 LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION ESTIMArEO SVAOEH ~ EA RESPONSE tO COMPLY WTN 'S IHPOAMATION COI.LECTION REQVESt. SOO HAS POR<<RO COMMENTS REGAAOING SVAOEH ESTIMATE 'tO THE RECOROS AHO AEPOATS MANAGEMENT SRAHCH IP 6201. V.S, NUCLEAR REGULATORY COMMISSION WASHING'tON OC 206$ 5. AHO TO THE PAPERWORK AEOUCTION PRO(SOT 121S001041 OPPICE OP MANAGEMENTAHO SUOGE't, WASHINGTON, OC 20SOS PACILII'VNAME 111 DONALD C.

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) 6I9 I 5I OIOI 1 IOIO )0 I -Io" 0 l 3 Conditions Prior to the Occurrence Unit One was in Mode 1 at 100 percent power, Unit 2 was in Mode 1 at 100 percent power.

Descri tion of Event On January 6, 1995 at approximately 0815 hours0.00943 days <br />0.226 hours <br />0.00135 weeks <br />3.101075e-4 months <br />, the Unit 2 fire detection monitor panel switch (EZZS)/IC-HS) was taken to the "off" position by a technician performing a routine surveillance.

The technician then left the Control Room without restoring the panel alarm function.

The panel switch was in the HoffA position for approximately 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> before it was discovered at 1112 hours0.0129 days <br />0.309 hours <br />0.00184 weeks <br />4.23116e-4 months <br /> and restored to the "on" position.

The fire detection monitor panel switch (EZIS/ZC-HS) is a cut-out switch for the Pyrotronics fire detection system installed throughout the unit and in various site office buildings.

Zn the "off" position, visual and audible alarms associated.with the fire detection zones will not alarm in the Control Room.

During the 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> that the switch was in the AoffA position no visual or audible alarms could be received in the Control Room, causing the fire detection system to be inoperable without proper compensatory measures being taken.

Cause of Event

This event is attributed to personnel error.

The procedure for the surveillance being performed,

• • 12 THP 6030. IMP.153, allows the monitor panel switch (EIZS/IC-HS) to be taken to the HoffA position momentarily to reset alarms at the panel.

However, the procedure also specifically states that the technician at the panel is responsible for ensuring that the Control Room alarm functions are restored prior to leaving the test panel unattended.

The technician placed the switch in the AoffA position and then exitect the Control Room.

A lack of understanding of the function of the switch contributed to this event.

It was not understood until after the event, while reviewing the applicable print, that placing the switch to AoffA would defeat all Unit 2 fire detection.

al sis of Event This event was determined to be reportable on January 26, 1995 pursuant to aOCFR50.73(a)(2)(i)(B) as operation prohibited by the plant's Technical Specification.

Technical Specification 3.3.3.8 requires that within one hour, an hourly fire watch patrol be established if more than one half. of the fire detectors in any fire detection zones are inoperable.

With the fire detection monitor alarm switch in the "off" position, all Unit 2 fire detection was inoperable.

HAC Pone SSSA ISSSI

NRC SORM ESSA losel U.5. NUCLEAR RKQULATORYCOMMISSION LICENSEE EVENT REPORT {LER)

TEXT CONTINuATION ArrROVEO OMS HO. 2150410$

ESTIM EO 4VROEH rER RESrONSE TO COMrLY WTH THIS IHSORMATION COLL'ECTION REQUEST: 500 HRS. fORWARO COMMENTS REQAROING SVROEN ESTIMATE TO TNE RKCORO5 AHO RKrORT5 MAHAQEMEHTSRANCH Ir 520I. V.S. NUCLEAR REGULATORY COMMI551ON. WASHIHQTOH. OC 20555. ANO TO THE rArERWORK REOUCTION rROJECT 1215041041. OffICE Of MANAGEMENTAHO KUOQET.WASHINGTON.OC 20502.

fACILITYHAMS 111 DONALD C.

COOK NUCLEAR POWER PLANT UNIT 2 COCKET NUMKER (2I YEAR LER NUMK~ R I~ I a ~ SSQUSNTIAL aA rrVM ta AtVrtlON NUMB A rAQK ISI TEXTN mare aaaaa e eeffaeerr.

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3 Anal sis of Event continued In the event of a fire, a "Fire System Actuation

" or

.RC02 Header Pressurized" alarm would still have annunciated in the Control Room for those areas provided with fire suppression capabilities.

Routine security patrols and operator tours were ongoing in the areas'onitored by the fire detection system but not having fire suppression capabilities.

In addition, multiple Un't 2 fire detection zones were being toured in support of other fire protection concerns.

Based on this, the event did not represent a significant safety concern.

At no time was the health or safety of the public jeopardized.

Corrective Action

Upon discovery, the switch was restored to the "on" position and testing was completed.

To prevent recurrence, labels have been placed on the control panel for each unit at the monitor switch.

The label cautions personnel against leaving the switch in the "off"position and states the results of leaving it in. that configuration, including the Technical Specification which must be entered.

Similar Events

'315/93-003-01 Failed Com onent 1dentification None HRC farra 254A 10451