ML20059M688

Intervenor Exhibit I-MFP-F3,consisting of Re LER 1-92-008-00 Concerning Missed Fire Watch Caused by Personnel Error

ML20059M688
Person / Time
Site:	Diablo Canyon
Issue date:	08/20/1993
From:	Rueger G PACIFIC GAS & ELECTRIC CO.
To:
References
OLA-2-I-MFP-F3, NUDOCS 9311190242
Download: ML20059M688 (10)

Text

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i Pacific Gas and Electric Company 77 Beaie Street ,,

Gregory M Rueger San Francisco CA 941W:, d U Senior Vice President an::

415 973-455; ' Oi C Gene.a Ma.ayr Nuclea Pue: Gene t=

'93 OCT 28 P6 :27 July 22,1992 a 't 7 PG&E Letter No. DCL-92-164 3-M i)

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U.S. Nuclear Regulatory Commission ATTN: Document Control Desk y g' c.

Washington, D.C. 20555 3 Re: Docket No. 50-275, OL-DPR-80 Diablo Canyon Unit 1 Licensee Event Report 1-92-008-00 Violation of Technical Specification 3.7.9.2 Due to a Missed Fire Watch Caused By Personnel Error

Gentlemen:

Pursuant to 10 CFR 50.73(a)(2)(1)(B), PC&E is submitting the enclosed Licensee Event Report concerning a violation of Technical Specification 3.7.9.2 due to a missed fire watch caused by personnel error.

This event has in no way affected the health and safety of the public.

Sincerely, au 4d' p l Gregory M. Rueger cc: Ann P. Hodgdon John B. Martin

_, Ph,jjip J. Morrill *-

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1 LICENSEE EVENT REPORT (LER) ',.

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DIABLO CANYON UNIT 1 0l5l0 0l0l2l7l5 1 'l 6 l mu . VIOLATION OF TECHNICAL SPECIFICATION 3.7.9.2 DUE TO A HISSED FIRE WATCH CAUSED BY l PERSONNEL ERROR EYmfDATE#5)

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(Spectfy in Abstreet below and in text, NRC Form 366A)

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RAYMOND L. THIERRY, SENIOR REGULATORY COMPLIANCE ENGINEER " ' ' ' '

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On June 24, 1992, at 0012 PDT, with Unit 1 in Mode 1 (Power Operation) at 100 percent  !

power, the 1-hour limiting condition for operation for the action statement of Technical l Specification (TS) 3.7.9.2 was not met for Unit I when the required continuous fire watch was not performed for certain safety-related equipment rooms.

The sprinkler fire water to the component cooling water and centrifugal charging pump areas was isolated in accordance with an equipment tagout request without the Shift l Foreman noting that a continuous fire watch was needed. An hourly fire watch was '

patrolling in the affected area.

The root cause of the event is personnel error on the part of the Shift Foreman. His review of the equipment tagout request was insufficient to determine the correct fire watch requirements.

The corrective actions for the event will include: (1) counseling of the Shift Foreman and the operators involved regarding the importance of establishing TS-required fire watches when approving requests, and (2) An Operations Coordination Instruction will be issued to include establishing required fire watches as the first step on equipment tagout requests that affect fire protection systems.

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I. flant Conditions Unit I was in Mode 1 (Power Operation) at 100 percent power.

II. Description of Event A. *1 mary:

On June 24, 1992, at 0012 PDT, the 1-hour limiting condition for operation (LCO) for the action statement of Technical Specification (TS) 3.7.9.2 was not met for Unit I when the required continuous fire watch was not performed in the component cooling water and centrifugal charging pump areas.

B.

Background:

TS 3.7.9.2 requires that within one hour of a required spray and/or sprinkler system being rendered inoperable, a continuous fire watch must be established with backup fire suppression equipment for those areas in which redundant systems or components could be damaged.

C. Event

Description:

On June 23, 1992, at approximately 2000 PDT, an equipment tagout request isolating the fire sprinkler system protecting the component cooling water and centrifugal charging pump areas was approved by the Unit 1 Shift Foreman. The tagout request allowed a drain valve in the fire sprinkler system to be replaced. The Shift Foreman did not note the instructions that stated a continuous fire watch was necessary as required by TS 3.7.9.2 action "a". The Shift Foreman then gave the request, along with the other equipment tagout requests to be processed during the shift, to the Unit 1 Senior Control Operator.

In processing the equipment tagout request, neither the Senior Control Operator nor the Auxiliary Operator actually implementing the requests noted the instructions on the equipment tagout request, which stated that a continuous fire watch was required when the system was out-of-service.

On June 23, at 2312 PDT, the sprinkler fire water to the component cooling water and centrifugal charging pump rooms was isolated in accordance with the equipment tagout.

The completed tagout request was returned to the control room on June 24 at 0620 PDT. At that time, the Shift Foreman reviewed the completed equipment tagout request and noted that a continuous fire watch was required. He contacted the Fire Watch Supervisor at this time to arrange for the continuous fire watch.

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On June 24, 1992, at 0700 PDT, the required continuous fire watch was established. Because the 1-hour LCO to establish a continuous fire watch was exceeded, action statement "a" of TS 3.7.9.2 was not met.

D. Inoperable Structures, Components, or Systems that Contributed to the Event:

None.

E. Dates and Approximate Times for Major Occurrences

l l

1. June 23, 1992; at 2000 PDT: Shift Foreman approved the tagout request.

2. June 23, 1992; at 2312 PDT: Sprinkler fire water to cantrifugal charging pump and component cooling water pump area was isolated.

3. June 24, 1992; at 0012 PDT: Event Date. The 1-hour LCO for TS 3.7.9.2 action "a" was exceeded.

4. June 24, 1992; at 0620 PDT: Discovery Date. The Shift Foreman identified that a continuous fire watch was required.

5. June 24, 1992; at 0700 PDT: Continuous fire watch was established and TS 3.7.9.2 action i "a" was satisfied.

F. Other.Jystems or SecondarLfunctions Affected:, ,

None.

G. Method of Discovery:

The Shift Foreman discovered the need for a continuous fire watch while reviewing the completed equipment tagout request.

H. Operator Actions: i Upon realizing that a continuous fire watch was needed, the Shift Foreman contacted the Fire Watch Supervisor and arranged for a continuous fire watch.

I. Safety System R:sponses:

None.

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Ill. Cause of the Event A. Immediate Cause:

The immediate cause of the event was that a continuous fire watch was not posted within one hour in accordance with TS 3.7.9.2 action statement "a".

B. Root Cause:

The root cause of the event was personnel error by a licensed Shift Foreman. Upon reviewing the equipment tagout request, the Shift Foreman did not identify the TS requirements.

C. Contributory Causes:

The Senior Control Operator and the Auxiliary Operator failed to identify that a continuous fire watch would be required once the-sprinkler system for the component cooling water and centrifugal '

charging pump area was rendered inoperable.

IV. Analysis of the Event The continuous fire watch was not performed for 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and 48 minutes. Had a fire occurred while the continuous fire watch was not present, the fire would have been identified by smoke detection equipment or by the hourly fire watch.

Fire oppression equipment (fire exting"4-hers, hose stations) was readily I available in adjacent fire areas for use by the Fire Brigade. '

Since a fire would have been detected and extinguished during the period that the sprinkler system was unavailable and the continuous fire watch was not present, the operability of equipment was not jeopardized, and the health and safety of the public were not affected by this event.

V. Corrective Actions A. Immediate Corrective Actions:

1. On July 24, 1992, at 0700 PDT, a continuous fire watch was established.

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8. Corrective Actions to Prevent Recurrence: l l 1. The Shift Foreman and operators involved will be counselled  !

regarding the importance of establishing TS-required fire watches when implementing equipment tagout requests. l

2. An Operations Coordination Instruction will be issued to include the establishment of the required fire watch as the first step

on any equipment tagout request tnat renders TS-required fire

protection inoperable.

i VI. Additional Information l A. Failed Components:

None, i B. Previous LERs on Similar Problems:

1. LER l-91-015-00, Violation of Technical Specification 3.7.10 When an Hourly Fire Watch Patrol was Not Performed Due to Inadequate Instructions The root cause was determined to be that no written instructions existed to ensure that TS-related fire barrier impairments would be inspected hourly during unexpected conditions that could delay fire watch personnel. Corrective actions included written instructions to fire watch personnel on actions to take if delayed during rounds and an incident summary of this event that was reviewed by all fire watch personnel. For the current event, the Fire V'+ch Supervisor was not notified of the need for a continuous watch; therefore, the previous corrective actions would not have prevented the current LER. ,

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2. LER 2-87-012-00, Personnel Error Results in Failure to Meet Technical Specification 3.7.9.3 Limiting Condition for Operation l for the Cable Spreading Room Cardox System i The root cause was personnel error in that the fire watch did not comply with the instructions on the fire watch log and he misunderstood his duty to remain on station until the Cardox system was returned to service. The corrective action was to remind all fire watch personnel of the importance of not leaving a fire watch post until the cardox system was returned to an automatic condition. The current event did not involve a fire watch misunderstanding his duties; therefore, the previous corrective action would not have prevented the current LER.

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LICENSEE EVENT REPORT (LER) TEXT CDNTINUATION

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3. LER 2-86-003-00, Personnel Error Results in Failure to Meet the Limiting Condition for Operation of Technical Specification 3.7.9.3 for the Cable Spreading Room CO, System The root cause was personnel error in that a construction worker and a maintenance worker, on two separate occasions, failed to comply with the administrative procedure for fire system impairment. The workers, who were also the fire watch personnel, left the area while serving as fire watches.

The corrective actions included special training for construction personnel to reemphasize the importance of complying with AP NPAP C-Il3, " Fire System Impairment."

Because the current event was not caused by fire watch personnel, the previous corrective actions would not have prevented the current LER.

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