ML17328A518

LER 89-015-00:on 891128,pyralarm Fire Detection Zone 3 Made Inoperable When Welding in Laundry Room Caused Standing Alarm.Fire Watch Patrol Not Assigned within 1 H.Caused by Personnel Error.Event Reviewed w/operators.W/891228 Ltr

ML17328A518
Person / Time
Site:	Cook
Issue date:	12/28/1989
From:	Blind A, Sampson J INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-015-01, LER-89-15-1, NUDOCS 9001050275
Download: ML17328A518 (7)

Text

ACCELERATED UTION DEMOM)TlMYION SYSIRM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9001050275 DOC.DATE: 89/12/28 NOTARIZED: NO DOCKET I, FACIL:50-315 Donald C. Cook Nuclear Power Plant, Unit 1, Indiana & 05000315..

AUTH. NAME AUTHOR AFFILIATION SAMPSON,J.R. Indiana Michigan Power Co.

BLIND,A.A. Indiana Michigan Power Co.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 89-015-00:on 891128,pyralarm fire detection zone inoperable w/o required roving fire watch.

W/8 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:

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

NOTES:

RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD3-1 LA 1 ' PD3-1 PD 1 1 GIITTER,J. 1 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DS P 2 2 DEDRO 1 1 NRR/DET/ECMB 9H 1 1 NRR/DET/EMEB9H3 1 1 NRR/DET/ESGB 1 1 NRR/DLPQ/LHFBll 1 1 8D'RR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB11 1 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB 8D 1 1 ' NRR/DST/SICB 7E 1 1 NRR/DST/SPLB8D1 1 NRR/DSZ/ BXB 8E 1 1 NUDOCS-ABSTRACT 1 ' 1 1 RES/DSIR/EIB 1 1 1 1 EXTERNAL: EGGG WILLIAMS,S L ST LOBBY WARD 1' LPDR NRC PDR 1 1 NSIC MAYS,G NSIC MURPHY,G.A 1 - 1 NUDOCS FULL TXT NOTE TO ALL "RIDS" RECIPIENTS'LEASE HELP US TO REDUCE WASTE! CONTACI'HE DOCUMENT CONTROL DESK ROOM Pl-37 (EXT. 20079) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISIS FOR DOCUMENTS YOU DON'T NEEDl FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 38 ENCL 38

Indiana Michigan Power Company Cook Nuclear Plant P.O. Box 458 Bridgrnn, Ml 49106 616 465 590I INDINCL NlCHIGAN PMAR December 28, 1989 United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating License DPR-58 Docket No. 50-315 Document Control Manager:

In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ortin S stem, the following report is being submitted:

89-015-00 Sincerely, (3/it~+~.

Blind Plant Manager AAB: c lw Attachment.

CC: D.H. Williams, Jr.

A.B. Davis, Region III M.P. Alexich P.A. Barrett J.E. Borggren R.F. Kroeger NRC Resident Inspector J.G. Gi'tter, NRC R.C. Callen G. Charnoff, Esq.

Dottie Sherman, ANI Library D. Hahn INPO /in

/pv 9

PNSRC S.J. Brewer/B.P. Lauzau

~OVID. iO "'7 i ogg~p2,~

ADr:rC:j ri.',rigor ~:;

F 5r:.

NRC Form 355 US. NUCLEAR REOULATORY COMMISSION (503)

APPROVEO 0MB NO. 31500101 EXPIRES: 8/31/85 LICENSEE EVENT REPORT {LER)

FACILITY NAME (I I DOCKET NUMBER (2) PA D. C; Cook Nuclear Plant, Unit 1 0 5 0 0 0 3 1 5 1 OF Pyralarm Fire Detection Zone Inoperable Without, Required Roving Fire WAtch

~

Due to Personnel Error EVENT DATE (5) LER NUMBER (5) REPORT DATE (7I OTHER FACILITIES INVOLVED (SI MONTH DAY YEAR YEAR ddaudnvrAL t~'. MONTH DAY YEAR FACILITYNAMES DOCKET NUMBER(SI NUMSER NUMS 1 R 0 5 0 0 0 1128 89 9 0 1 5 0 01 2 2 8 8 9 0 5 0 0 0 OPFRATINQ THIS REPORT IS SUBMITTED PURSUANT 7 0 THE REDUIREMENTE of 10 cF R I'I: /carte onr or mort ol rhr Iol(owlnp/ l11 MODE (8) 20.a02(el 20.405(cl (iv) 73.71(5) 50,73(a I (2 I POWER 20.a05( ~ Ill)(0 50.38 (c) Ii) 50.734(l2) (v) 73.71(cl LEVEL 1 p p 20A05( ~ lll)(ill . 50.35 (e) (2 I 50.73(a)(2) (vi) OTHER ISptclly ln AOrtrrct t>>irw mr/ In Trxt, HIIC FOrm 20.a05( ~ I(1 Hi(i) X 50.73(al(2)li) 50.73(r)(2)(viiil(A) i 35dA/

20A05( ~ I I I ) (Iv) 50.73(al(2) IN) 50,73(a) (2) (vii()(8) 20.405( ~ I(1) (v) 50.73(a l(2) l ii)) 50.73(a)(2)(xl LICENSEE CONTACT FOR THIS LER (12I NAME TELfPHONE NUMBER AREA CODE J. R. Sampson, Operations Superintendent 616 465 -5901 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

SYSTEM COMPONENT MANUFAC REPORTABLf MANUFAC EPORTABLf (~o~~~ig@@g@g CAUSE, TVRER TO NPRDS CAVSE SYSTE M COMPONENT TVRER kNIII SUPPLEMENTAL REPORT EXPECTED I(ai MONTH DAY YEAR EXPECTED SUBMISSION DATE Ud)

YES III yn, COmpltrt EXPECTED SUI/ar/$ $ /ON DATE/ NO ABSTRACT ILimlt ro tr00 u>>ctr. / rapprox/mrttly /i learn rlnplt.rot et typtwntrtn linn/ I'IS)

On 11-28-89 at 1140, the pyralarm fire detection. Zone 3 for the of the Auxiliary Building was made inoperable when welding in the 609'levation laundry room caused a standing alarm. Due to an operator error, a fire watch patrol was not assigned within one hour to tour the zone each hour while the zone was inoperable.

At 1400 on 11-28-89, the Zone 3 pyralarm fire detection became operable.

When the Unit Supervisor notified the Fire Watch Dispatch to release the of the Auxiliary Building from the roving fire watch tour, the Unit 609'levation Supervisor was informed that no fire watch had been assigned.

This event was discussed with the involved Control Room operators. The operators are fully aware of their responsibilities to correctly read components labels and to maintain good communications in the Control Room.

NRC Form 355 IS 83)

NRC Fovm 3SSA U.S. NUCLEAR REGULATORY COMMISSION (SS3)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMS NO. 3150&(0d EXPIRES: 8/31/88 FACILITY NAME (I( COCKET NUMBER (3) LER NUMBER (SI PAGE (3)

'dg SEGUENTIAL .oSE/ REvvssoN YEAR NUMSEII v..vS NUMSEA D.C. Cook Nuclear Plant Unit 1 o so oo315 0 1 5 0 0 0 2oF 0 5 TEXT li/ move sosse is vsdvvived, oso eddie'ovve///RC Fovm 3ESA's/ (IT(

Condition Prior to Occurrence Unit 1 in Mode 1 operating at 100% power.

Unit 2 in Mode 1 operating at 100% power.

Descri tion of Event On 11-28-89 between 1140 and 1400', the Unit 1 (U-1) pyralarm fire detection (EIIS/ID-DEC) Zone 3 (609'levation Auxiliary Building) was inoperable as a result of a standing alarm due to welding activities in the 609'uxiliary Building L'aundry Room. Contrary to U-1 Technical Specifications (TS) 3.3.3.7 (Fire Detection Instrumentation) and Plant Manager Standing Order (PMSO) .095 (10 CFR 50 Appendix R Alternate Safe Shutdown Requirements) a fire watch patrol was not established within one hour to inspect the inoperable zone at least once per hour.

The following is a summary of the events that led up to this error.

On 11-28-89 during the 08-16 shift, a Senior Reactor Operator (SRO) assigned to the control panels received a call that welding would be taking place in the Seal Injection Filter (EIIS/CB-FLT) room on the 587'levation of the auxiliary building (pyralarm fire detection Zone 2). In addition, the SRO had been informed that hydrolazing was going to take place in the Unit 2 (U-2) Vest Residual Heat Removal (RHR) pump (EIIC/BP-P) room and that he could expect the pyralarm fire detection Zone 1 (587'levation Auxiliary Building) to alarm.

At 1140, the pyralarm abnormal alarm and two fire detection zone lights came in. The SRO assigned to the control panels acknowledged the alarm and checked the zone lights that had lit. The SRO felt confident that he saw Zone 1 (573'lev.) and Zone 2 (587'lev.) lights lit. Following the acknowledgement of the alarm, the SRO attempted to clear the alarm. The alarm cleared and came back in. The SRO acknowledged the alarm and noted that two zone lights were lit. The SRO assumed that the zone lights that and Zone were 3

lit were for Zone (609'lev.) were lit. Zone 1 and Zone 2.

2 Actually, (587'lev.)

Zone 1 (573'lev.)

was clear.

The SRO who responded to the alarm, notified the Fire Vatch (FV) Dispatch that the Zone 1 and Zone 2 were inoperable and requested a fire watch patrol to tour the 587'levation and 573'levation of the Auxiliary Building. A FV was assigned to tour the 587'levation and 573'levation each half hour.

Since, the SRO did not recognize that the Zone 3 light for the 609'levation of the Auxiliary Building was standing, a FV was not requested to tour the 609'levation of the Auxiliary Building.

NRC SCAM SSEA (8.8 3 I

NRC Form 3ddA

~ ~ U.S. NUCLEAR REGULATORY COMMISSION (9431 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVED OMS NO. 3150M(04 EXPIRES'/31/88 FACILITY NAME (11 OOCKET NUMSER (2) LER NUMSER (SI PAGE (31 YEAR 1 SEGVENTIAI, +'EVISION rr$>i

@$ NVMSER NVMddR D.C. Cook Nuclear Plant Unit 0 5 0 0 0 3 1 5 8 9' 0 1 5 0 0 0 3 OF 0 5 TEXT /// moro o/>>Io rr rodu/rod. uoo oddroor>>/HRC Form 3////AS/ II 2)

A second Reactor Operator (RO) assigned to the Control Room had been informed early in the shift that welding would be taking place in the 609'levation laundry room and that a FW was posted. In addition, the RO was informed that hydrolazing would be taking place in the 573'levation West RHR pump room.

When the pyralarm abnormal alarm and zone lights came in, the RO requested an operator to investigate the 609'levation to ensure the alarm was due to welding in the laundry room. The RO completed PMI;4031 (Event Initiated Surveillance) Attachment 1 (Event Initiated Surveillance Item Tracking Sheet) and 1-OHP 4030.STP.021 (Event Initiated Surveillance) Data Sheet No. 19 (Standing Fire Detection Alarm) for Zone 1 and Zone 3. In addition the RO completed OHI-2211 (IIaintenance of Operations Department Logs) Attachment-No.

3 (Open Items Form) for Zone 1 and Zone 3 to log the zones inoperable.

When the pyralarm detection alarm and lights came in, the U-1 Unit Supervisor (US) noted that the Zone 1 and Zone 3 lights were standing and that the PHI-4031 and OHI-2211 paperwork was being completed by the RO. The US also noted that the SRO assigned to the control panels had requested a roving FW.

The US assumed that the SRO had requested a roving FW for the 609'levation and 573'levation of the Auxiliary Building. The US made a Control Room Log Book entry at 1140 that Zone 1 and Zone 3 were inoperable and that a roving FW had been established.

At 1400 the Zone 3 pyralarm light cleared. The US called the FW dispatch to remove the 609'levation from the roving FW tour. The FW dispatch informed the US that a FW was touring the 573'levation and 587'levation of the Auxiliary Building per the"'ontrol Room call at 1140, but no FW had been requested to tour the 609'levation Auxiliary Building area.

r Cause of Event The cause of this even't is personnel error. The SRO who responded to the pyralarm and zone detection lights failed to correctly identify the zone lights that were actually lit.

Contributing to this event:

1. Due to his knowledge of hydrolazing in the RHR pump room and welding in the Seal Injection Filter room, the SRO who acknowledged the pyralarm had a preconceived idea as to which pyralarm detection zones he expected to see alarm.

2. A communication breakdown between the operators assigned to the Control Room contributed to this event. The operators failed to effectively communicate changes in plant status.

NRC FORM dddA 1983 I

NRC Form 3SSA U.S. NUCLEAR REOULATCRY COMMISSION (943) APPROVED OMB NO. 3150WI()4 LICENSEE EVENT REPORT ILER) TEXT CONTINUATION EXPIRES: B/31/(6 FACILITY NAME II) DOCKET NUMBER (3) LER NUMBER (S) PACE (3)

SEOUENTIAL REVISION YEAR NUM ER NUMBER D.C. Cook Nuclear Plant Unit 1 o 5 0 0 0 3' 5 8 9 0 1 5 OF TEXT //I moro NMco /o ro3wrod, ooo odd/oorro/Ar/IC Forrrr 3EBA3/ l(3)

Anal sis of Event The failure to assign a FW patrol within one hour to tour the inoperable fire detection area was a violation of Technical Specification 3.3.3.7 and is reportable under 10 CFR 50.73(a)(2)(i)(B).

The 609'levation of the Auxiliary Building pyralarm detection system was inoperable for about 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> and 20 minutes without a roving FW assigned to tour the area.

This analysis concludes that in the unlikely event of a fire, personnel would have been promptly aware of its presence, and would have been able to control and extinguish the fire without significant spreading of the fire or equipment damage. This conclusion is based on the following:

Although a FW was not assigned specifically to tour the 609'levation of the Auxiliary Building, a trained FW passed through a major part of the 609'levation area each half hour. The roving FW was assigned to tour the U-1 and U-2 Steam Generator Stop Valve Enclosure areas during the time the Zone 3 pyralarm detection was inoperable and passed through the 609'rea on the way to those zones. Had a fire occurred on the 609'levation of the Auxiliary Building, the fire would have been noted by the roving FW and corrective action would have been taken.

2. In addition to the roving FW passing through the 609'levation each half hour, plant personnel enter the Auxiliary Building on the Had a fire occurred on the 609'levation of the Auxiliary 609'levation.

Building, plane personnel passing through the 609'levation would have noted the fire and reported it to the Control Room.

3. The 609'levation of the Auxiliary Building is provided with a Preaction Dry Pilot Sprinkler System. This system has a compressed air pilot" line with sealed sprinkler heads rated at 175 F. Had a fire occurred, the seal would have broken and Control Room Annunciator 102 Drop 128 (Aux Building El 609 or El 633 Fire) or Annunciator 202 Drop 129 (Aux Building El 609 Spr. Abnormal) would have alerted Control Room operators to investigate the cause of the alarm and to take corrective action.

Based on the above, this event is not considered to have created a significant safety concern, nor did it create a significant hazard to the health and safety of the general public.

NRC FORM 3OOA (9 831

NRC Form 3ddA US. NUCLEAR REOULATORY COMMISSION (943(

LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVED OMB NO, 3(50&(04 EXPIRES: BI3(IBB FACILITY NAME OI DOCKET NUMSER (21 LER NUMBER (8) PACE (31 YEAR EEOUENTIAL REVISION NUMEEII NUMEE4 D.C. Cook Nuclear Plant TEXT IIImoro u>>ss is rsdrdrsd, oss sddrdor>>l IYRC Form 3EEA'sl (171 Unit <<<< o 3 ] 5 8 9 0 1 5 0 0 0 5 QF 0'orrective Action

1. Since Zone 3 was operable when the US noted no FM patrol was assigned to the 609'levation of the Auxiliary Building, no corrective action was required at the time this event was discovered.

2. This event was discussed with the SRO who failed to correctly identify the pyralarm detection zone lights that were standing. The SRO is fully aware of his responsibility to correctly identify a pyralarm by th'e zone light label.

3. This event was reviewed with each of the involved operators. Each operator is fully aware of his responsibilities to maintain good Control Room communications.

Fail Com onent Identification None Previous Similar Events A review of Licensee Event Reports did not reveal a previous similar event where an operator failed to correctly identify a standing pyralarm and therefore did not request a roving FW.

NRC FORM EEEA (9 83I