ML20044A385

LER 90-008-00:on 900525,Tech Spec Hourly Fire Watch Missed Due to Miscommunications Between Security Personnel & Radiation Protection Personnel.Fire Watch re-established & Memo issued.W/900625 Ltr

ML20044A385
Person / Time
Site:	LaSalle
Issue date:	06/25/1990
From:	Crowl D, Diederich G COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-008-04, LER-90-8-4, NUDOCS 9006290001
Download: ML20044A385 (6)

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., Commonw

alth Edison .

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.... 17 LaSalle County Nuclear Station -

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v' g . Rural Route #1,61341 Box 220 -

$ Marseilles,I!!inois p;< - Telephone 815/357 6761 i

June 25, 1990 Director of Nuclear Reactor Regulation U.S. Nuclear Regulatory <ccamiission Mail Station Pl-137 Washington, D.C. 20555 .

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Dear Sir:

1 l Licensee Event Report 990-000-00, Docket 9050-373 is being L submitted to your office in accordance with 10CFR50.73 (a)(2)(i).

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M b ) 7 G. J. Diederic [h Station Manager LaSalle County Station E GJD/DAC/1s 1 Enclosure i

xc: Nuclear. Licensing Administrator NRC Resident Inspector NRC Region III Administrator IMPO - Records Center L

9006290001 900625 g, PDR ADOCK 03000373 V s PDC ,

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. i LIC8 mat EVENT AkPORT (tit) Fem tev 2.0 Facility usme (1) Decket thaber (2) Penn (3) mile e- -tv statlan unit i , el 51 of of of 31 71 3 1 of e 5 litle (4) ysad techalcal lagciflamilan thgriv Fim Match the to MI' -itatlans

, inset hate (1) -

LEl - ^ - (6)  ; bate (7) Other Facilities ineolved (8)

Month Day Yeer Veer j/g seguential /g Revislen Month f

Day Year Fati1Itv "-- 7 T- d at " " ( s )

W/ /Y/ l tasalle unit 2 of 51 of ol 01 31 71 4

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of5 21 5 el o el o oIoIe o1e oI6 21 5 el o el51elelel l I )

TMil REPORT 15 $WRITTED PUR$uRNT TO THE IIEqulRE7ENTS OF 10CFR OPEMTING 1 (Chd one er more of the followina) (11) '

OI 30.402(b) _,,,, 20.406(c) ,_ 50.73(a)(2)(lv) 73.71(b) l ptRet ,_,. 20.405(a)(1)(l) ,,,,, 50.36(c)(1) _,,,, 50.73(a)(2)(v) _ 73.71(c)

LEVEL 30.406(a)(1)(ll) W.36(c)(2) ,, 50.73(a)(2)(vil) ,,,,,

other (specify 1 !0 (10) o ,_ 20.406(a)(1)(lll) _L, 50.73(a)(2)(1) ,, W.73(a)(2)(vill)(A) in Abstract

// // / / ,,,_, 20.405(a)(1)(lv) ,_,,, 50.73(a)(2)(ll) 50.73(a)(2)(vill)(c) below and in f/f f/ f f/ /f/f/ ff

/ 20.405(a)(1)(v) _,,_ 50.73(a)(2)(lit) ,,,,_ 50.73(a)(2)(a) Teat) ]

LICEN5EE CGriACT FOR THIS LER (12) l l lease iLLEPHONE IM GER AREA CODE Den A. Crevl. HPES Coordinator. estension 2460 8 1 1 15 31 51 71 -l 61 71 61 1 l CWFLLTE ONE LINE FOR EACH C090 MENT FAILURE DESCRIRED IN THIS REPORT (13)

$YSTEM COWOMENT MNUFAC-l

! CAUSE REPORTABLE CAUSE SYSTEM COWOMENT MANUFAC- REPORTABLE /jfe//

TUICR TO IIPWS TUI0R TO IrWE T l

i A 1 N 11 '

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$UPPLEMENTAL REPORT EXPECTED (14) Espected Month l Bay l tear submission

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lves (if ves. cam >lete EXPECTED $WMI5510N DATE) Il ND l l i ABSTRACT (Limit to 1400 spaces, i.e, approaleAt 9 fifteen single-space typewritten lines) (16) l On May 25, 1990 with unit 1 in the Run en es 100E power and Unit 2 in Md Shutdown with the Reactor vessel

( reassembly in progress, the Reactor building Refuel f;oor hourly fire rgM was not perfonned at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> I cs required by Technical Specifications (due to fire detection being inoperable). The missed fire watch

( occurred due to several causes which were as follow; (1) a miscommunication between the Security personnel who needed to perfom the fire watch and the Radiation Protection Personnel who needed to authorize Security to perform the fire wtch in a high radiation area, (2) due to shift turnover taking place at the time of this event, no personnel were located on the Refuel Floor to allow Security to phone them for verification that no sites were present and (3) inadequate radiation control practices lead to Security not belne able to perform the ?lre watch due to the spread of contamination. The fire watch was re established at 0013 hours1.50463e-4 days <br />0.00361 hours <br />2.149471e-5 weeks <br />4.9465e-6 months <br /> on May it, .990, I hour and 27 minutes following the previous fire watch and all responsible department personnel will be tallgated on this event. The safety significance of this event is alnleal because no work was lh progress prior to this event or during this event which would have Increased the potential for a fire to occur on the Refuel Floor, enty 27 minutes had elapsed since the fire watch was required to be perfonned.

This event is being sutanitted pursuant to the requirements of 10CRFR50.73(a)(2)(l) due to a deviation from l plant Technical Specifications.

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I E l a PMILITY WE (l) MTWWA(2) Las _ - 141 _ m as 0 11 Tear O/ Sequential yf Asvisten TY M7 that i tasalle emustr statlan unitL o i s i o 1 e i o I al 71 3 gio - oIeie - o Io el 2 er al l l Text tory insustry lesetithetten system (tils) codes are identified in the test as (xx] j

, pu wT Am $YsteM !OtNTiflCATim eeneral Electric - telling %ter Reactor Energ ladustry identification System ($115) codes are identified in the test as [xx].

A. COWITION PRIOR TO EVENT unit (s): jfL twent Date $/25/g0 twent flam: 2300 Hours I heactorMode(s): jf,L Powr tevel(s): Jgg Mode (s) names hun / Cold theidsun

8. DESCRIPTION OF AVENT on May 25,1990 with unit i in the Run made at 1005 power and unit 2 in Cold Sheldown, security uns assigned the task of perfonning hourly fire watches on the refuel floor. The fire watches teve required by LaSalle Techalcal Specification 3.3.7.g, because the nonna) fire detection (FP) [lC) system toes disabled to prevent nuisance or falso fire alems due to high radiation conditions which result fram moving the reactor vessel camponents (W) [AD] for reassembly. At 2246 hours0.026 days <br />0.624 hours <br />0.00371 weeks <br />8.54603e-4 months <br /> the last fire watch was perfomed for May 25, 1990, the subsequent fire watch was not perfomed untl10013 hours on May 26, 1990, therefore I hour and 27 minutes had elapsed since a fire watch us perforund.

Security was perfoming the required fire watcles by calling the refuel floor and questioning personnel in the area about whether or not they had seen any fires. This method was utilized to perfom the fire watch because the refuel floor area and the access to the refuel floor had became contelnated. The spread of centmination us caused by ventilation air flow through the refuel floor plugs. e During the reactor vessel reassembly, 2 Radiation Protection Technicians (RPT's) were assigned to the c refuel floor to control and monitor activities and one was assigned to the desk (located at the refuel >

floor access point on the Reactor buildint 832' elevation) to control the Radiation Work Pomit and '

assign digital ensleetry. No one was present on the refuel floor during this event due to shift crew turnovers which were taking place.

I At 2246 hours0.026 days <br />0.624 hours <br />0.00371 weeks <br />8.54603e-4 months <br />, the last person to leave the refuel floor was logged out and the security guard (Rever N) posted at the refuel floor access point questioned this person as to whether or not any fires were noted. This was the last 41se a fire watch was perfomed and documented for May 25, 1990.

At 2248 hours0.026 days <br />0.624 hours <br />0.00372 weeks <br />8.55364e-4 months <br /> the security guard (Rover N) was contacted by the fire watch security guard. Rever N notified the fire watch security guard that the match tours were satisfactorily completed.

At 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br />, both Operating and Maintenance department turnovers took place.

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te evert aspent (tnan Tant certa-flou tr- nov 2.0 i e

5 pMILITY WE (1) 001E11 apWER (2) LEA ^^ - = (6)

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+ 11. * ^ tsatlan udt i e i s i e i e i e 1 al 11 3 eIe - oIoIe - o Io el 3 or el5 i TEXT Energ lutustry lesotification Systa (Ells) codes are identified in the tent as [KX]

O. OtlCRIPfleu 0F IVONT (Continued)

At apprealantely 2360 hours0.0273 days <br />0.656 hours <br />0.0039 weeks <br />8.9798e-4 months <br />, the security guard posted at the refuel floor access point had nottfled his supervisor that everyone had left the refuel floor. The security guard was then Instructed by his supervisor to perfom his teactoi tullding tour and call the refuel floor when it can tlan to deement the fire watch. ,

I At the end of the security guard's tour, he called the refuel floor to verify no fires wre taking I place. No answr was received because no one was present on the refuel floor due to shift turnovers.  !

i At 2333 hours0.027 days <br />0.648 hours <br />0.00386 weeks <br />8.877065e-4 months <br /> the security guard (Rover H ) was apeln contacted by the fire watch security guard. Rever l N again notified the fire watch security guard that the watch tours wre cogleted.

i At approalsetely 2340 hours0.0271 days <br />0.65 hours <br />0.00387 weeks <br />8.9037e-4 months <br /> on May 25, 1990 the security guard called the security supervisor to notify i I

him that no one was on the refuel floor to facilitate completing the fire watch. At this ties the

security supervisor called the Radiation Protection (RP) supervisor. l

I in an investigation laterview with the RP supervisor, he had Indicated that Security had questioned him  ;

as to where t:ee RP1's were and that no mention was made to the RP supervisor as to the concern for

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perfoming the hourly fire watch. The MP supervisor did not ask security why they wre asking for the ,

IFT's locations. Mditional interviews wre held with security. The security supervisor who contacted  ;

the AP supervlur sentioned he had Indicated to the RP supervisor that no one was positioned at the desk on the Reactor tullding 832 elevation for access to the refuel floor. During the laterview the Security i i

supervisor had sentioned that the AP supervisor responded by saying that he had people on their way up there (Reactor tullding 832 elevation, at access point to the refuel floor). The Security supervisor said he had told the RP supervisor that he needed to perfom the fire watch. The conclusion of the ,

Intervlows indicated a misconnunication between the RP supervisor and the Security supervisor.

i At 0013 hours1.50463e-4 days <br />0.00361 hours <br />2.149471e-5 weeks <br />4.9465e-6 months <br /> on May 26, 1990, an entry was made onto the refuel floor and the fire watch re estabilshed '

using personnel working in the area on the Unit 2 Reactor vessel reassembly.

C. - APPARENT CAUSE Of EVENT f I ,

Poor ceumunication practices lead to the failure rf the radiation protection supervisor to reallae the need tc insure security had access to the refuel floor, it was not until ofter the event that security was infomed that they could do a visual floor inspection from the doorway of the refuel floor when no ons was present on the floor.

Poor canuunication practices also lead the fire watch security guard into believing the fire watch was completed at 2333 hours0.027 days <br />0.648 hours <br />0.00386 weeks <br />8.877065e-4 months <br /> and the fire watch security guar 11 logged the fire watch complete at this time.

On May 22,1990, at 1800 hours0.0208 days <br />0.5 hours <br />0.00298 weeks <br />6.849e-4 months <br />, inadequate radiation work practices lead to the loss of contamination control by the refuel floor doorway which prevented security from being able to perfom a doorway inspection of the refuel floor for fires, i

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t sumart amant itsai tant conti==ttan Fem ano 2.s  !

c* PMILITY INE (l) MCEEi lap M A (f) lea _ _ 16) Puma 0 l} [

Year 5eguential Apelslon  :

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%Ile e- tv statlan =lt 1 e 1 5 1 e i e i e 1 al 11 3 eio - o1eie - o Io el4 nF cl i  !

TEXT Energ Industry idestification System (Elll) codes are identified in the test as [KR) j C. APPARENT CAUSE OF EvtNT (Continued)

Shift turnover for all personnel on the refuel floor occurred at the same time resultlne in no one belne I pewsont on the refuel floor to 411ew security to perfom the fire watch by ca111ag the refus) floor for verification that no fires wre occurring.

0. SAFETY An4LY515 0F EVtWT t

The design of the hefuel floor fire detection system does not allow for t%e system to remain operable during high background radiation conditions which result during reactor m sel assembly and l disassembly. This requires a fire watch to be estab11shed during these conditions as required by ,

LaSalle Technical Specifications.  ;

t The fire detection system is nomally bypassed for areas in which wlding, grinding or other activity in y progress that actuates the system, in these situations a fire watch is estabilshed to provide for '

adequate detection and waming of fires which may result. The probability of a fire occurring durint

this event was alnloal because no work was in progress at the time due to turnovers taking place and no work was in progress prior to this event Ithat would have required an increase in the capability to '

d detect fires.

E. C0ARECilVE ACTIONS A fire watch was re-established as soon as personnel entered the refuel floor to continue vessel reassembly work activities. Security personnel wre Instructed to continue perfoming the fire watch by calling the refuel floor and questioning personnel on the floor as to whether or not there were any fires, if no personnel were available on the floor, security was infomed that they could perfom the fire watch by opening the refuel floor door and perfo m a visual check of the floor from the doorway.

This was done to minimize dose and any potential for cont mination. The hourly fire watch was re-established at 0013 hours1.50463e-4 days <br />0.00361 hours <br />2.149471e-5 weeks <br />4.9465e-6 months <br /> on May 26, 1990. This was I hour and 27 minutes after the previous fire watch.

The Security Administrator issued a security memorandum to Instruct security personnel to notify the Shift Engineer laundlately when a fire watch is unable to be perfomed. ,

A tellgate for both Security and Radiation Protection personnel on this event with emphasis placed on the Igoriance of good communication practices will be conducted. The tallgates will also include a discussion for Security to take compensatory measures during turnover periods. The coupletion of this i

! corrective action will be tracked by Action item Record (AIR) neber 313-200-90-04401.

1 A review of the feasibl11ty to set up a Refuel Floor camera, with a monitor located at the Refuel Floor i access point on the heector Building 832' elevation to allow security to monitor for fires and minimize dose and the potential for contamination will be performed. The coupletion of this corrective action <

will be tracked by AIR neber 373-200-90-04402.

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s LT ~7 EURIK M (tsal TERT tmK'"" TIM Fare hv 2.0 '

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4 FAtiLITY WE (1) SetRET 18508R (2) LER r _- - (6) pine Cl)  !

Year Sequential / Revision

% 11e - ^_, statlan r 1 e i n i o 1 o I o I al 113 e1o - 0IoIe - oIo el 5 or el 5 i TEXT Energ ladustry identification Systa (Ell 5) codes are identified in the text as [XX) .

E. CORRECTIVE ACTieu5 (Continued)

A LaSalle A hinistrative Procedure will be developed, or a revision to the entsting procedures, to -

provies guidance as to who can perform a fire watch and what constitutes a fire watch. This procedure or revision will include guleance on transferring the fire watch responsibility between one work group to another. The cespletion of this corrective action will be tracked by AIR nueer 373-200 00-44403.

A revision to security post orders to provide guidance to lanediately notify the Shift Engineer when a i fire watch cannot be performed will be issued. The coupletion of this corrective action will be tracked  ;

by AIR nueer 373-200-00-04404.

A review of procedures for the reactor vessel disasseely and reassaely to provide Instruction to insert that the refuel floor plugs are properly sealed will be conducted. This will force ventilation .

flow te erd the reactor well to prevent the potential for spreading containation during the movement of f reactor vessel components. The completion of this corrective action will be tracked by AIR numer 373-200-00-04405.

F. PIIEVIOUS EVENTS

( Ilone l, G. C090utNT FAILURE DATA Ilone I

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