ML20006E966

LER 90-003-00:on 900115,discovered That Fire Watches Not Established Prior to Removing Deluge Sys for Trains a & B Reserve Station Svc Transformers from Svc.Caused by Personnel Error.Personnel counseled.W/900214 Ltr

ML20006E966
Person / Time
Site:	Millstone
Issue date:	02/14/1990
From:	Freeman P, Haynes H NORTHEAST NUCLEAR ENERGY CO., NORTHEAST UTILITIES
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-003, LER-90-3, MP-90-169, NUDOCS 9002270010
Download: ML20006E966 (5)

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wYsI."mY[aSIMnNieNcompen7 N asY E n N Ni E .'N any P.O. BOX 270 HARTFORD. CONNECT 10VT 06414-0270 tervoast Neien* Enre, company (203)666-6000 February 14, 1990 MP-90-169 Re: 10CFR50.7?ia)(2)(i) 3 U.S. Nuclear Regulaiory Commission Document Control Desk Washington, D.C. 20555

Reference:

Facility Operating License No. NPF-49 Docket No 50-4.3 Liceissee Event Report 90-003-00 Gentlemen:

This letter forwards Licensee Event Report 90-003-00 required to be submitted within thirty (30) days pursuant to 10CFR50.73(a)(2)(i), any condition prohibited by the plant's Technical Specifications.

Very truly yours, NORTHEAST NUCLEAR ENERGY COMPANY FOR: Stephen E. Scace Direct , Millstone Stat' n BY: Harry \ .H ne. \

v Millstone U(nl rvices Direc SES/PAF:tp

Attachment:

LER 90-003-00 cc: W. T. Russell, Region 1 Administrator W. J. Raymond, Senior Resident Ins >ector. Millstone Unit Nos.1, 2 and 3 D. H. Jaffe, NRC Project Manager, Millstone Unit No. 3 hk

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The root cause of the event was personnel error. The designated senior licensed operator (SRO),

responsible for reviewing and authorizing AWOs, failed to document the need for a hre watch patrol at the

• A" and *D" RSSTs. The hre watch patrol documentation was required at the time of AWO autMnzation. The Day SS failed to realire that a fire watch patrol had not been established at the

• A*

and "B" RSST dunnp his review of the hre watch log. +

As action to prevent recurrence, the Operations Department Supervisor has counseled the personnel invohed on attention to detail when removing hre detection systems from service. Procedural piidance to assist in determining the compensatory actions for removing Fire Detection and/or Suppression systems from ,

service, will be provided by April 15,1990.

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F ACUTY NAME (1) DoRET N.A4th m t rt4 yunt o efa 6*GI IN vt Ast P!** N Millstone Nuclear Power Station Umt 3 0l f,l 0l 0l 0l4 l2 l3 4l0 0l 0l 3 0l0 0l 2 OF 0 j .3 un of mo.. spec. .. rea,- c. use .umi.onai une to*m m A s, o n l, beWTfNiuf! f)I E \ Pfit On January 15, 1990, at approximately 1530 hours0.0177 days <br />0.425 hours <br />0.00253 weeks <br />5.82165e-4 months <br />, at 1009 power (Mode 1), the Shift Supervisor ,

dncovered that the proper fire watches had not been established prior to removmp the *A* and

• D" Train Reserve Stauon Services Transformer (RSST) Delure Systems from service. This dehtiency was found during a review of completed Automated Work Order (AWO) packages.  :

The unit staff failed to fulfill the requirements of Techtlical Specification 3.7.12.1, " Spray and/or Sprmkler Systems," before exiting the associated Limiung Condiuon for Operanon (LCO). The duration of the esent was approximately 8 hourk.

On January 14, 1990, at approximately 2150 hours0.0249 days <br />0.597 hours <br />0.00355 weeks <br />8.18075e-4 months <br />, the Fire Protection Console was declared ,

moperable upon indication of control system circuitry malfunction. Fire watch patrols were establahed in accordaner ulth the requirements of the Technical Specifications for all applicable local hre rone panels. On January 1$,1990, at approximately 0730 hours0.00845 days <br />0.203 hours <br />0.00121 weeks <br />2.77765e-4 months <br />, the senior hcensed operator (SRO) designated for the review and authonzation of AWO packages, reviewed un AWO

• to perform repairs on the Fire Protection Console. The Delure Systems for the "A" and *B* train RSSTs were to be taken out of service, as one of the prerequisites for the planned repairs. Fire watch requirements were discussed between the designated SRO, the Day Shift Supervisor and the Millstone Station Fire Marshall to ensure proper bre watch patrols were invoked. Upon establishing fire watch requirements, the design;ned SRO authorired the AWO ternovmp the Deluge Systems for the " A" and "B* RSSTs trom service, but failed to piepare the documentation required to estabbsh the necessary hre watch patrols. The Day Shift supervisor reviewed the hie  ?

watch log at approximately 0830 hours0.00961 days <br />0.231 hours <br />0.00137 weeks <br />3.15815e-4 months <br />, but did not notice that fire watch patrols had not been established at either the *A* or "B" RSST, On January it3,1990, at approximately 1530 hours0.0177 days <br />0.425 hours <br />0.00253 weeks <br />5.82165e-4 months <br />, the on-coming shift supervisor, during his review of cernpleted AWOs discovered the fire watch patrol dehciency invoh1ng the *A* and *B" RSST Deluge System. As immediate corrective action, the Delupe Systems for the *A* and *B" Train RSSTs were returned to service, since repairs to the Fire Protection Console had been completed.

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11. Cnuse of Event The root cause of the event was personnel error. The designated SRO failed to prepare i documentation to establish a hre watch patrol at the " A" and

• B" RSST. The hre watch patrol '

documentation was required at the time of AWO authorization. The Day Shift Supervisor failed to realire that a hre watch patrol had not been estabbshed at the *A* and "B" RSSTs dunng his review of the hre watch log.

N4C Form 366A (6-$0)

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F Act.fTY NAME t t) DOctET NJMisER G1 iFo y M rp ,ti } 6 AGE 0:

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Ill. Atahsis of Eient .i e

This event is reportable under the requirements of 10CFR50.73(a)(2)(i), as a condition prohibited by the plant's Techmcal Specifications. Technical Specification 3.7,12d.,

• Spray and/or Spnnkler Systems," requires that fire watch patrols be estabbshed wnhm an hour, uheneser the Deluge ,

Systems for the

• A* and "B' RSST are inoperable.

Fire suppression for the affected areas consists of (butomatic) heat actuated Deluge Systems. The ,

h secor:dary suppression system for the affected crea consists of the unit Fire Bntade. With the Delure System out of servae, fue suppression capabihties become degraded. Due to equipment location, the traffic of plant personnel in the affected area, and rouune inspections of the affected area, adequate warning of a hre was available to Operation department personnel All hydrant hose houses were operable for the duration of this event.

In the event of a hre in the affected area, a redundant source of off-8ite power was available (via the Normal Station Service Transformers (NSSTs)) throughout this event. The NSSTs are physically removed from the RSST, thereby precluding the compromise of both sources of off-site pour m the event of a fire in one area. Addiuonally, both the "A* and "B" Train Emergency Diesel Generators were operable throughout this evem, and therefore available to supply safeterslated plant loads in the event of a loss of off-site power, IV. Corrective Action immediate corrective action was to restore the deluge system for the "A" and *B" RSST to operable status. As action to prevent recurrence, the Operations department supervisor has counseled the personnel involved in this event, on attention to detail when removmg fire detection systems from service, in order to assist shift supervisory personnel in determining the compensatory actions required prior to removmg a Fire Detection and/or Suppression system from service, an Operations department procedure will be developed specifying the required actions to be taken.

The anticipated completion date for this procedure is April 15, 1990.

V. Additional Information LER 67-029, " Failure to Post Fire Watches Due to Operator Error " discusses an event in which fire watches were not properly instructed as to the boundanes of the patrol for areas where the Fire Suppression System was removed from service. The corrective actions / actions to prevent recurrence were to incorporate guidance in the procedure for deactivation of CO2 to clearly state the requirements of fire watches in multi-level areas, to require verification of a posted fire watch for AWOs performing work in areas harmg CO2 fire suppression, and to centralize the reFponsibihty of fire watches under the control of the Operations Department.

LER 8F-025. " Failure to Post Firewatch with Degraded Fire Protection Due to Procedural

' Deficiency," discusses an event in which an hourly fire watch was not established in the A Train

) 4160 VAC Smtchgear Room after fire detection had been degraded. The root cause of the event was personnel error, wherein a non-heensed operator inadvenently bumped a switch adjacent to the one being tested, in addition, the surveillance procedure did not explicitly hst the fire panel alarms expected during the test. The correctise action / action to prevent recurrence was to modify appbcable procedures to ensure proper local zone panel operation, prior to, and post testing, and to include the appropriate alarm response.

Nec Form 366A (6-60)

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LER 68-027 *Mislocated Fire Wateb Due to Personnel Error," discusses an event in which are houri) fire watch was posted in the southern area vice the south HYAC area of the Engineered Safety Features Building, due to miscommunication between plant personnel. A memo was issued by the Operations Department Supervisor to all Shih Supervisors emphasizing the need for verifymg communicated information and the need to utihre all applicable procedures. A clear description of l fire detection tone locations was to be mcorporated into the applicable procedure by February 26, 1989.

LER 89-004, " Inoperable Fire Detection Due to Operator Error," discusses events where automatic fire detection in areas of the Containment buildmg and the Diesel Generator fuel oil vault had been unavailable due to miscommunication and an inadequate alarm evaluation. As corrective e actions / actions to prevent recurrence, all on-shift personnel would be briefed of the need for i prompt evaluation and response to all fire system alarms. In addition, a Task Force of personnel from the Engineering, Operations, and Instrurnentation and Controls departments, was formed to evaiuate Fire Protection and Detection system performance and to evaluate the human factors aspects of information provided to plant operating personnel. 1 Th: corrective actions in LERs67-029, 88-02$ and 88-027 were directed toward correcting specific deficiencies. The corrective actions in LER 89-004 were directed towards improving the performance of the Fire Protection and Detection system trom an operations and human factors -

aspect. The corrective actions / actions to prevent recurrence for the aforementioned events would not have prevented the event discussed in this LER. The reason being that personnel in this event were aware of the need to estabhsh fire watch requirements in the subject areas, but failed to ensure that the tequired compensatory actions were implemented due to a cognitive failure. The proposed corrective action will reduce the likelihood of the recurrence of a similar event by proceduralising the required compensatory actions for degraded fire detection and suppression systems.

Ells Codes '

Systems Fire Detectica System - IC Fire Protection System - KP I Comnonents Inter-Tie Transformers (RSSTs) - XFMR 1

i NRC Form 366A (6-691