ML19324B251

LER 89-012-01:on 890720,discovered That Master Solenoid to Switchgear Room Halon Sys Disconnected Since 890629.Caused by Personnel Error Resulting from Lack of Written Procedure. Procedure Revised to Apply Temporary mods.W/891027 Ltr

ML19324B251
Person / Time
Site:	Calvert Cliffs
Issue date:	10/27/1989
From:	Bell G, Russell L BALTIMORE GAS & ELECTRIC CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-012, LER-89-12, NUDOCS 8911020284
Download: ML19324B251 (8)

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CHARLES CENTER e P.O. BOX 1475 e BALTIMORE. MARYLAND 21203 1475 l totytet Clif ts butttaa P9mm PLANT MPAnimWT  ;

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l October 27, 1989 i i

U. ',S Nuclear Regulatory Commission Docket No. 50 317 -

Document Control Desk License No. DPR 53  ;

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Dear Sirs:

t The attached IIR 89 012, Revision 1, is being sent to you as required under 10 CFR 50.73 guidelines, t

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Should you have any questions regarding this report, we would be pleased to l discuss them with you.  ;

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[ Very truly yours, &

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L. B. Russell Manager Calvert Cliffs Nuclear Power Plant Department i

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cc: William T. Russell .

Director, Office of Management Information i and Program Control ,

Messrs: G. C. Creel i C. H. Cruse l l

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At approximately 0200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> on July 20, 1989, with Unit 1 shutdown, a technicien discovered a master solenoid to the Switchgear Room Halon System to be disconnected.

Upon discovery, the llalon System was immediately declared inoperable and an hourly fire watch was established. The solenoid was reconnected and the solenoid was verified OPERABLE by a functional test.

Further investigation indicates that the solenoid was last taken out of service on June 29, 1989 and then inadvertently lef t disconnected. The root cause of this event is personnel error resulting from the lack of a written procedure for performing this task. Contributing causes include an inadequate procedure for addressing fire system impairments and the failure to apply temporary modifications and Safety Tagging procedures to this task.

Corrective actions include: revising a procedure to apply temporary modifications and Safety Tagging to fire systems; revising a Surveillance Test Procedure for verifying placement of solenoids; installing identification tags on solenoids; installing warning signs on llalon Systems; conducting a Quality Assurance Surveillance on applicability cnd working knowledge of procedures; establishing a written procedure for disabling colenoids; and conducting training.

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1, DESCRIPTION OF EVENT At approximately 0200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> on July 20, 1989, with Unit 1 shutdown (MODE 5 Cold Shutdown), a Fire and Safety Technician (FAST) (utility, non licensed) discovered that a master solenoid (1.ERV.2) to the Unit 1 Switchgear Room Halon System was disconnected. This solenoid actuates the discharge of Halon from three of nine Halon cylinders located on the west vall of the 45 foot elevation Switchgear room (See Figure 1). This disconnected solenoid was discovered during the routine performance of Surveillance Test Procedure (STP) M 291 0, *Halon System Valve Position Verification." However, the Halon System Master Solenoids are not checked as part of this STP and, therefore, the performance of the STP did not directly contribute to the discovery of this event.

Upon discovery of the disconnected solenoid, the Shift Supervisor was informed and the Halon System was immediately declared inoperable. The ACTION STATEMENT for Technical Specification 3.7,11.3, *Halon Systems," was entered and an hourly fire watch was established. The solenoid was inspected for damage and returned to its normal position, however, the ACTION STATEMENT remained in effect until an OPERABILITY determination could be made.

Even though there was no indication of damage to the solenoid or associated equipment, a functional test was performed to verify OPERABILITY, A maintenance order (MO No. 209 201 573A) was initiated and OPERABILITY of the solenoid was verified by performing Section VII of FTP.M 699 1, " Functional Test of 27' and 45' Switchgear Rooms Automatic Halon Release Solenoid Circuit." Upon satisfactory completion of the te:s t , the Halon System was declared OPERABLE wad the ACTION STATEMLNT was exited at approximately 1300 hours0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br /> on July 20, 1989.

Further investigation into the event showed that the solenoid was last documented I to be out of service between approximately 0830 and 0840 hours0.00972 days <br />0.233 hours <br />0.00139 weeks <br />3.1962e-4 months <br /> on June 29, 1989.

! A FAST had performed a fire system impairment tagout at this time in accordance I with Calvert Cliffs Instruction C01 133, "Calvert Cliffs Fire Protection Plan".

The Halon System for the 27. foot and 45. foot Switchgear rooms was disabled by disconnecting each of the three master solenoids from its ass ociated Halon cylinder bank. This is the standard procedure for disabling a Halon System when work being performed in a room might cause an inadvertent actuation of the Halon System. In this instance, maintenance technicians wanted to heat a motor generator cot.pling on the 27. foot level Switchgear room.

The FAST who performed the tagout on June 29, 1989 believes that it was unlikely I that he lef t one master solenoid disconnecced. However, CCI.133 did not require independent verification of the fire system impatraent tagout. Therefore, there was no independent verification by any other personnel that all three master l solenoids were actually reconnected on June 29. During the investir,ation, it was also reported that the master solenoids were observed to be in place on July 14, 1989. This observation occurred during an informal walkdown of the Halon System I which was being conducted for the purposes of procedure development. However, this observation was not documented. No maintenance or other activities were identified during the period between June 29 and July 20 which would require the

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Room. Consequently, since it cannot be determined beyond a reasonable doubt that l the master solenoid was reconnected on June 29, we conclude from the documented evidence that the solenot.d was inadvertently left disconnected.  !

11. CAUSE OF EVENT ,

The root cause of this event was determined to be personnel error resulting from the lack of an approved, written procedure for rendering the Halon System inoperable by disabling the three master solenofds. Activities which modify fire protection systems described in the Technical Specifications are required to be prescribed and accomplished in accordance with documented instructions, procedures, and drawinga. This task was incorrectly considered to be within the skills normally possessed by qualified personnel of the craft and, therefore, the FAST was unaware that a procedure was required. Contributing causes to this event are as follows.

CCI.133, 'Calvert Cliffs Fire Protection Plan" did not adequately address the method for taking fire detection or suppression systems out of service. C01 133 did not reference CCI 117 " Temporary Modification Control." The purpose of CCI.117 is to ensure that the disabling, bypassing, or changing of systems, sub systems, or components by some form of temporary modification will be properly reviewed for safety consequences, documented, and controlled. The task of disconnecting the solenoids was not recognized as a temporary modification to the plant. The use of CCI.117 would have required an independent verification to ensure that all of the master solenoids had been returned to service before declaring the Halon System OPERABLE.

In addition, CCI-133 did not adequately address when Safety Tagging is required or its relationship to Fire System Impairment Tagging. CCI.112. " Safety Tagging" was not referenced by CCI.133. The purpose of CCI.112 is to establish procedures for the tagging of equipment to ensure the safety of personnel and to ensure no adverse effect on operating equipment. . Fire System Impairment Tags were placed on fire detection and suppression equipment whenever they were taken out of service for maintenance. Due to the ambiguity of these instructions, a Safety Tag was considered not to be required for this task.

The investigation also revealed that the Halon System master solenoids did not have identification tags. Also STPs M 2910 and M 6991 did not have distinct verification and sign offs for each Halon System station.

III &HALYSIS OF EVFNr Total floodf.ng Halon 1301 Automatic Fire Suppression Systems are provided for the l

45. foot elevation and the 27 foot elevation Switchgear rooms. The Halon storage and distribution system is designed such that the same banks of bottles can supply Halon to either room depending on which room has the fire. There are three banks of bottles: one bank contains four bottles and only discharges to the 45 foot

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discharge in the event of a fire in the 45 foot elevation Switchgear room. The ,

master solenoid for the three bottle bank was disconnected, which would have prevented this bank from discharging for a fire in either Switchgear room.

Halon 1301 (Bromotrifluoromethane CBrF3 ) is theorized to extinguish fires by  !

inhibiting the chemical chain reaction of the combustion process. As a result, Halon performs its function in very small concentrations as compared to other gaseous extinguishing agents such as carbon dioxide, which depends on oxygen displacement. NFPA 12A, the standard for Halon 1301 fire extinguishing systems, considers a 5% concentration sufficient for the types of fires anticipated in the Switchgear rooms. In fact, the appendix section of this code indicates that the flaming phase of combustion will be extinguished with even lower concentrations.

This is based on tests performed by the telephone industry on wired telephone distribution frames which consistently achieved complete extinguishment with less  !

than 5% Halon concentration.

An evaluation of Halon concentration with the three bottle bank unavailable was performed. An initial calculated concentration of approxiwately 6% was available l for the 45. foot elevation Switchgear room and approximately 3.45% for the 27 foot Switchgear room. It can be concluded that the Halon system, even with the three bottle bank inoperable, would have prevented fire spreading within the room as well as outside the room. Our bases for this conclusion are provided below:

. In the 45. foot Switchgear room the initial discharge concentration of 6%

is above the recommended extinguishing concentration of 5% for this type of room.

. In the 27 foot Switchgear room the initial discharge concentration of 3.45%, while below the recommended extinguishing concentration, would have stopped flaming combustion and thereby prevented a fire from spreading.

. The detection systems which actuate the Halon systems were functional.

These systems provide an alarm indication to the Control Room. In addition, these systems utilize smoke detectors which respond much faster to fire conditions than heat detectors. Therefore any fire leading to discharge of the Halon System would still have been in an incipient stage.

. The plant fire brigade would respond to a fire in time to provide  !

extinguishment of glowing combustion still remaining after the Halon discharge.

Therefore, there is reasonable assurance that the safety of the plant and the public was not significantly compromised by the event.

At approximately 0930 hours0.0108 days <br />0.258 hours <br />0.00154 weeks <br />3.53865e-4 months <br /> on July 20, 1989, a Determination of Reportability (CCI 118, Event No. 3425) was initiated to evaluate the event. NRC Region I was informed of the event at approximately 0935 hours0.0108 days <br />0.26 hours <br />0.00155 weeks <br />3.557675e-4 months <br /> in accordance with 10 CFR 50.72 (b)(2)(1).

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of I 015 0F oli i mw . , w e.,. = v mi This event is reportable under 10 CTR 50.73 (a)(2)(1)(B) as a condition prohibited by the plant's Technical Gpecifications. Technical Specification 3.7.11.3 requires that an hourly fire watch be established in those areas protected by an inoperabje Halon System. This requirement was not met on June 29, 1989, when the Halon System for the Unit 1 Switchgear rooms was returned to service and the fire watch was discontinued with the solenoid still disconnected. Technical Specification 3.7.11.3 also requires that a Special Report be sent to the Commission within 30 days of the Halon System being inoperable for over 14 days.

This requirement was not met as a result of changing the event date from the date of discovery, July 20, 1989, to June 29, 1989. Therefore, the event occurred from approximately 0840 hours0.00972 days <br />0.233 hours <br />0.00139 weeks <br />3.1962e-4 months <br /> on June 29, 1989, to 1300 hours0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br /> on July 20, 1989, a duration of approximately 21 days. Written procedures are required by Technical Specificatien 6.8.1 and Regulatory Guide 1.33, Rev. 2, ' Quality Assurance Program Requirements . Operation" to be established, implemented and maintained for the Fire Protection Program. This requirement was not met as a result of not having a procedure for disabling the Halon solenoid. The reportability date of the original LER was determined to be 30 days from the discovery date. There were no other inoperable or failed components, structures or systems which contributed to this event. No other plant system or components failures resulted from this event.

IV. CORRECTIVE ACTIONS A. Immediate Corrective Actions The following corrective actions were taken on July 20, 1989:

. Upon discovery of the event, the Halon System was declared inoperable and an hourly fire watch was established in accordance with Technical Specification 3.7.11.3.

. Af ter inspecting the solenoid for any noticeable damage, the solenoid was connected back to its Halon bank. Therefore, though remaining ,

inoperable by Technical Specifications, the Wlon System was functional.

. The solenoid was functionally tested satisfactorily and declared OPERABLE.

B. Short term Corrective Actions i

The following corrective actions were taken on July 22, 1989:

. Safety and Fire Protection Unit personnel were instructed that work performed in accordance with CCI.133 requires independent verification .

. The Manager Calvert Cliffs Nuclear Power Plant Department issued a roemo to ensure that the control and tagging of impaired firo protection equipment meet the requirements of CCI 112 as well as CCI.133.

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of 1 al6 0F 017 no n . , w o ,,ami.vnn C. Long term Corrective Actions The following corrective actions have been taken as a result of this event:

. CCI.133 has been revised to discontinue the use of fire system

, impairment tags and, instead, will reference CCI.112 Safety Tagging requirements. CCI.133 will ali.o require the use of C for teal.orary modifications to fire detection and suppression sys,CI tems. 117

. STP.M 291 0 has been revised to require verification that llalon actuator solenoids are in place. The STP has also been revised to have distinct verification and sign. offs for each Halon System station.

. STP.M 699 1 has been revised to have distinct vertiication and sign. offs for each llalon System station.

. Identification tags have been installed on llalon master solenoids.

. Warning signs, have been pinced near llalon cylinder banks which state,

' EIRE SUPPRESSION SYSTD( DO NOT DISTURB VIT110VT PERMISSION, CALL FIRE PROTECTION UNIT: X.4755/4931."

The following corrective actions will be taken as a result of this event:

. A Quality Assurance Eurveillance will be conduct.ed to: (1) evaluate if CCI 112 and 117 are applicable to any other plant activities not currently being applied co these CCIs and (2) determine if plant p9rsonnel (sample selected from cognizant disciplines) have an adequate working knowledge of CCIs 112, 117, and 133.

. Fire and Safety petsonnel will receive training on the revised requirements of CCI 133 and CCI.117.

. A written procedure will be established for disabling and restoring the Halon System master solenoids.

V. ADDITIONAL INFDRMATION l

Four previous events affecting the llalon System have occurred at Calvert Cliffs.

Details of these events may be found in LERs 7814, 7818, c.nd 78 41 for Unit I and 78 40 for Unit 2.

Identification of components referred to in the LER are:

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