ML19351A637

LER 89-028-00:on 890524,fuel Bldg roll-up Door Opened While Fuel Movement in Progress,Causing Loss of Fuel Bldg Integrity.Caused by Miscommunication Between Personnel. Procedures Re Fuel Bldg Doors strengthened.W/891214 Ltr

ML19351A637
Person / Time
Site:	Millstone
Issue date:	12/14/1989
From:	Mcdaniel D, Scace S NORTHEAST NUCLEAR ENERGY CO., NORTHEAST UTILITIES
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-028, LER-89-28, MP-13861, NUDOCS 8912200094
Download: ML19351A637 (4)

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N s to Serv any P.O. BOX 270 HARTFORD. CONNECTICUT 06414-0270 "3 Nortteast New Energy Company (203)666-6000 1

.x December 14, 1989 MP-13861-

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Re: 10CFR50.73(a)(2)(vii) ,

, - .S$ Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555

Reference:

. Facility Operating License No. NPF-49 Docket No. 50-423 Licensee Event Report 89-028-00 Gentlemen:

This letter forwards Licensee Event Report 89-028-00 required to be submitted pur-suant to the Notice of Violation contained in Inspection Report 50-423/89-14 and 10CFR50.73(a)(2)(vii), any event or condition where a single cause or condition caused

.two, or more independent trains to become inoperable in-a single system designed to mmgate the consequences of an accident.

Very truly yours, NORTHEAST NUCLEAR ENERGY COMPANY

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M1~L au l StepMen E. Scace Station Superintendent Millstone Nuclear Power Station - i SES/DTM:mo

Attachment:

LER 89-028-00 cc: W. T. Russell, Region I Administrator W.-J. Raymond, Senior Resident inspector, Millstone Unit Nos.1, 2 and 3 D. H. Jaffe, NRC Project Manager, Millstone Unit No. 3 e

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e i- NRO f orm 366 APPHOVED OM3 NO 3160-0104 U.S NUOLEAR REGULATORY COMMISStON

.(649: e ' , EXPIRE S: 4!30 T2 Estimated buroen per resoonas to comply with this ,

s . information conection reauest: 60 0 hrs Forwarc  !

LICENSEE EVENT REPORT (LER) . won'0*a'na"o'ef.'nUNMo'i u"E 'llei.ar Regulatory Commission Washington DC 20555 and to i tne Paperwork Recuetion Prose 01 (3150-0104L Ottice of 1 Management and BucDet. Washington. DC 20503. I F ACILITY NAME (1) .

DML1 NVMbW WI Pa M ' I h1illstone Nuclear Power Station Unit 3 of 51 of ol ol4 l213 1lOFl 0l 3 j TO LE 14)

Fuel Building Integrity Lost During Fuel hiovement Due to Open Door Caused by Personnel Error l E VE NT DAT E ($1 LER NUMBER #61 REPORT DATE (71 OTHER F ACluTIEB INVOLVED (8)

MONTE DAY YEAR YE AR

@ MONTH DAY YEAR EACldIYNAME6 ols101olof I i l

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0 5 2l4 8 '9 8 l9 0l2l8 0l 0 1l2 1l4 8l 9 ol slo lolol l l OPERATING THIS REPORT 15 BEM SUBM;TTED PURSUANT TO THE REOJiREMENTS OF 10 CFR l' (Check one or more of the tohowino)(11) 20 402td) 20 402tc) 60.73(a H2) tiv) 73.711D) p R 20 405ta)(1H4) 60.361c H11 60 73(aH2ilv) 73.71(c) vio, 0l0l0 20.40sias ti)(ii) 50 3 sic)(2) 2 60.73. ia)(2)t vio 1 Text(T;(R, aggiig, 20 40$(aH1)(iii) 50.73ia)(2HO 60.73(aH2Hvuo( A) NRO Form 366A) 20 405taH1Hiv) 60 73ial(2Hl0 60. 73 t a)(2 H viin (B) 20 405ta)fintivi 60 73(aH2HHO 60 73ta)(2Hx) l LICENSEE CONT ACT FOR THIS LER (121 >

NAME TELEPHONE NUMBER ARLA CODi David T. SicDaniel. Engineer, Ext, 4381 2l0l3 4l4l7l-l1l7l9l1 COMPLETE ONE LINE FOR E ACH COMPONENT FAFLURE DESCR: BED IN THfS REPORT #131 CAUSE SYSTEIV COMPONENT hhk* 7d CAUSE SYSTEU COMPONENT hhk ~

l i I I I I I I II I I I I I II I I I I I II I I I I SUPPLEMENTAL REPORT EXPECTED f *4) MONTH DAY YEAR g

SUBMS$10N DATE 06)

YES (19 yes. comoiste EXPECTED SUBMIS$10N DATE) M NO l l l ABSTRACT <umn to u00 spaces, e e . acoroximate>y inteen sinoie-soace igewrnten un.si osi On Niay 24, 1989, while shutdown for refueling, in Slode 6, at 0 ri power, 89 degrees and atmospheric pressure, the fuel building roll-up door was opened while fuel movement was in progress. This made the fuel buildmg ventilation system incapable of maintaming a slight negative pressure as designed during fuel handling. Immediate corrective action was to stop fuel handling until the door could be closed.

The root cause of this event is miscommunication between personnel. Security procedures require that the con,rol room be contacted to obtam permission, prior to opening the door. The security console operator stated that he contacted the Shift Supervisor (SS) and obtained permission to open the door. How ever, the SS reported that Security personnel never asked for permission. The specific cause of the

• miscommunication could not be determined, Corrective action was to strengthen administrative controls on opening fuel building doors.

L This LER is being reported as required by the Notice of Violation contained in Routine Inspection Report 50-423/89-14.

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(- l NRc torm 366A - 'V.S. NUCLEAR nioVLAToRY COMMISSION APPROVED OhJ No. 3150-0104

,j6-69)- , . E XPIRE S : 4 /30 '92 .

p Y . Est, mated burden per responto to comply with this LICENSEE EVENT REPORT (LER) pf mlg',cg'*y *a477846,0,f,";$g ,',"Agd ,,

b TET CONTINUATION .no R. ports uanao. ment Branch (p-63DL U S. Nuc6 ear Regulatory Commission. Wasnington DC PO555. and to

i. the Paperwork Recuction Pro <ect (3160-010at ottice of Management ene Bacoet Washington. DC 20503.

F ACli.rTY NAME (1) DOCKET NUMBER ill LF A NUMBF A 16 6 PAGE 131 YEAR Millstone Nuclear Power Station Unit 3 0l 6l 0l ol 0l4 l2 l3 8l9 0l2l8 0l0 0l 2 OF 0l3 TEXT Ut more space is recuired use additional NRO Form 366A s) (17)

1. Descrintion of Event At 1532 on May 24,1' 989, while shutdown for refueling in Mode 6 at Or cpower, 89 degrees, and atmospheric pressure, the fuel building roll-up door was opened while fuel movement was underway L in the fuel building. This was discovered immediately by plant personnel. The fuel assembly then i

being lowered into the storage rack was completely inserted at 1540, and further fuel movement was hahed,

11. Cause of Event The root cause of this event is miscommunication between personnel. Secunty procedures require that the control room be contacted to obtain permission, prior to opening the door. The secunty console operator stated that he contacted the Shift Supervisor (SS) and obtained permission to open the door. However, the SS reported that Secunty personnel never asked for permission.

The specific cause of the miscommunication could not be deterrained.

111. AnMrsic of Event 1 This event is being reported as required by the Notice of Violation contained in Inspection Report 50-423/89-14. Per the Notice of Violation, this event should have been reported pursuant to 10CFR50.73(a)(2)(vii) as an event where a single condition caused two independent trains or channels to become inoperable in a single system designed to control the release of radioactive material, Although the building could no longer be maintained at a slight negative pressure, the ventilation system still would be able to control the release of radioactive material sind would have provided l adequate protection to the environment. The fuel building ventilation system is designed to provide  !

supply air at the louer levels of the building, and exhaust at upper levels of the building  !

surrounding the pool. Although the building was not at a negative pressure, any release that might j have occurred would still have (xited the building through the exhaust filters. The flow of air l would have been from the open door on the 24-foot level of the building to the exhaust ducts at the SI-foot and above levels in the fuel buildmg. Any airborne release at the surface of the pool,  !

cn the-51-foot level, would exit the building through the exhaust ducts located above the pool.

The ventilation system remained in service and would have performed its intended safety function - ,

to control the release of radioactive material. l This event was initially evaluated as being not reportable on the basis that Technical Speciftcations f requirements were met. Since the Technical Specifications were followed, and given the short

-duration of the event, no significant adverse safety consequences ensued. As such, this event was considered to be not reportable and the unit did not submit an LER within thirty days of the event.

l l ' Corrective Action -

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I L The immediate corrective action was to lower the fuel assembly that was in motion into storage and i l suspend any further fuel movement until the roll-up door could be closed.

Corrective action to prevent recurrence consisted of:

1. Posting signs at the fuel building doors which state that the Shift Supervisor (SS) and Security must give permission prior to opening the doors.

2. Revising fuel-handmg procedures to require danger tagging doors shut when fuel buildmg integrity was required.

I NRC Form 366A (6-89)

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i(6-89) EXPIRE S: 4;30 n2 L

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Estimated buraen per response to comoty with this F- LICENSEE EVENT REPORT (LER)-

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to s3oi. nc u s Nuciear Repuistory Commission, Washengton. DC 20656 snc to tne Paperwork Reouction Project (3150-0104). othee of ManaDement aM Buttpet W a shington DC 20603 FACluTY NAME f1) DOOKET NUMBER (2) (F A NtugE A rei PAGE13)

YEAR Millstone Nuclear Power Station ~~ ~

Unit 3 OF 0l 3 0[ 5l 0l ol 0l4 l2 l3 8l9 0l 2l 8 0l0 0l 3 TEXT (11 more space is recusred. use additional NRc Form 3t>6A 8) (17)

Yl . . Corrective Action (Continued)

3. Implementing a policy for operations personnel to notify security when fuel buildmg integnty is required.

-4. Establishing a secunty log I'., record times when permission is granted from the SS to open or block doors at the statior.

5 .- Modify work orders to identify fuel building integrity doors.

6 Modifying the

• Requests for Security Door / Gate Coverage," procedure to correctly identify which doors require security coverage.

Y, Additionn) Information There have been no similar events with the same root cause and sequence of events.

Ells Codes System Comnonent

. Fuel Building - ND Door - DR 4 Fuel Building Environmental  !

Control System - VG l

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f NRC Form 36CA (6-89)