ML20196G582
| ML20196G582 | |
| Person / Time | |
|---|---|
| Site: | South Texas  |
| Issue date: | 06/23/1999 |
| From: | Head S HOUSTON LIGHTING & POWER CO. |
| To: | |
| Shared Package | |
| ML20196G571 | List: |
| References | |
| LER-99-S02, LER-99-S2, NUDOCS 9907010206 | |
| Download: ML20196G582 (4) | |
Text
- APPROVED BY oMB NO. 3150-0104 NRC FORM 366 '
U.S. NUCLEAR REGULATORY COMMISSloN Estinnted buren pr response to comply with dus mimdatory EXPIRES 06/30/2001 l
, mfornsoon collection i6-1998) requat: 50 hrs. Reponed bssons learned are mrc2purated mio the hcensmg prcress j
~ and led back to mdustry. Forward comnrnts regardmg burden estmmte to t!w 1 LICENSEE EVENT REPORT (LER) EN "nT'SI555 o'E"a'dioUe'A M o N M " D $"5"o'iC Office f Manaprnrnt and Budget, Wastungion DC 20503. If an mfornmuon collection does not display a cunently vahd OMB control number the "RC nay not (See reverse for required number of conduct or sponsur, and a person is not reqmred to respond to, the infornmuon digits / characters for each block)
FACILITY NAME(1) DOCKiri NUMBER (2) PAGE(3)
South Texas Unit 1 05000 498 1 of 4 TITER (4)
Failure to Maintain Positive Control of Vital Area Security Key
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EVENT DATE (5) I.ER NUMHER (6) REIT)RT DATE (7) l OTIIER FACILITIES INVOLVED (5)
MONTH DAY YEAR YEAR AL kg5gN MONHi DAY iEAR FACILrrY NAME DOCKET NUMUER SQU R 05000 DOCKET NUMBER l FACILITY NAME 06 01 1999 1999 S02 00 06 23 1999 1 05000 OPERATING TIIIS REPORT IS SUBMITITD PURSUAVr TO TIIE REoPIREMEN'IS OF 10 CFN 6: (Check one or more) (1l}
MODE (9) 6 20.2201(b) 20.2203(aK2Hv) 50.73(aK2Mi) 50.73(aK2Xviii)
POWER 20 2203(aWI) 20 2203(a W3Vi) 50 73(aV2Xii) 50 73(ax2 Kx)
LEVEL (10) Refueling 20.2203(ax2xi) 20.2203(ax3xii) 50.73(a x2 xiii) X 73.71 g; V e%;g 20 2203(aW2yii) 20 220Vaw4) 50 73(aV2Wiv) o'DIER gy{ihi g MM* 20.2203(aX2glii) 50.36(cX1) 50.73(aW2Xv) Specify in Abstruci below or in W A U.; @ib ' 20.2203(aX2Wiv) 50.36(cx2) 5073(aW2)(vii) NRC Furm 366A I,1CENSEE CONTA("I FOR TIIIS I ER (12)
NAME TELEPiloNE NUMHER (include Area Code)
Scott Head - Licensine Supervisor (512)972-7136 COMPIEIT ONE I.INE FOR EACII COMIT)NENT Fall URE DESCRIHED IN TIIIS REPORT (13)
CAUSE SYSTEM COMPONENT MANUFAC'IURER REPORTABM CAUSE SYSTEM COMPONENT MANUFACTURER REIORTABLE TO LPIX ,
TO LPIX r.
SUPPL.FMFNTAL REPORT EXPECTrn (14) EXPE(' RED MONTil DAY YEAR YES x NO SUHM1SSION (if yes, complete EXPECTED submission DATE) DATE (15)
ABSTRACT (Linut to 1400 spaces,i.e.. approxirnately 15 single-spaced typewntten hnes) (16)
On June 1,1999, at 0757 hours0.00876 days <br />0.21 hours <br />0.00125 weeks <br />2.880385e-4 months <br />, the Nuclear Regulatory Commission was notified that vital area keys were reponed missing by Operations personnel. A Unit 1 Plant Operator lost control of a vital area security key which was contained on the Electrical Auxiliary Building watch station key ring. The key ring was not reported lost for approximately seven hours. Immediately upon notification of the lost keys the security force posted all vital areas until change out of vital door key cores was completed. At 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br /> on June 1,1999, the keys were found and returned to the Unit 1 Shift Supervisor. The security computer system records were reviewed to verify that the keys were not used in an unauthorized manner while missing. The root cause of the event was lack of attention to detail to ensure control of the vital area key was maintained. The operator's lack of knowledge pertaining to the consequences of lost vital area security key resulted in his failure to immediately report the keys missing. This event is considered reponable to the NRC under 10CFR73.71(b) because a vital area key was discovered missing; and compensatory actions to ensure that the lost key was not used in an unauthorized manner; were not instituted within ten minutes.
Corrective actions include discussing the event with the operator involved in accordance with the Constructive Discipline Program, and communicating the event with Operations personnel via night orders and during Operations requalification training lessons learned.
- 9907010206 990623 PDR ADOCK0%4yB S
j
NRC F0161366A U.S. NUCLEAR REGULATORY C051NtISSION
@ l998)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAh1E 0) DOCKET LER NUhtHER (6) PAG E 0)
South Texas, Unit 1 05000 498 I W Ik" Ma" 2 of 4 99 -- S02 -- 00 TEXT (ifmore space is required use additional copies ofNRC Form 366A) (17)
DESCRIPTION OF EVENT On June 1,1999, at 0757 hours0.00876 days <br />0.21 hours <br />0.00125 weeks <br />2.880385e-4 months <br /> the Nuclear Regulatory Commission was notified that vital area keys were reported missing by Operations personnel. A Unit 1 Plant Operator lost control of a vital area security key which was contained on the Electrical Auxiliary Building Watch station key ring. Operations watch station key rings contain various keys used for routine tasks along with the security vital area key. The key ring was not reported to be lost for approximately seven hours.
I At 2209 hours0.0256 days <br />0.614 hours <br />0.00365 weeks <br />8.405245e-4 months <br /> on May 31,1999, the Unit 1 Electrical Auxiliary Building Operator entered #13 Diesel Generator Building to hang Equipment Clearance Order A-5828 which required valve SD-0008C to be closed. This valve is normally locked open. The operator unlocked valve SD-0008C using the Electrical Auxiliary Building Watch ]
sct of keys, positioned the valve as required by the clearance, and walked away leaving the set of keys in the lock. At approximately 2220 hours0.0257 days <br />0.617 hours <br />0.00367 weeks <br />8.4471e-4 months <br /> a second operator independently verified the position of valve SD-0008C i for the Equipment Clearance Order. Both operators exited the Diesel Generator Building at 2223 hours0.0257 days <br />0.618 hours <br />0.00368 weeks <br />8.458515e-4 months <br />.
At approximately 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> on May 31,1999, the Electrical Auxiliary Building Operator noticed that he did not have his watch station keys in his possession. He began questioning himself as to the location of the keys.
He rationalized that he must not have received the keys at shift turnover. He did not remember using the keys earlier during the shift for the execution of the Equipment Clearance Order. The operator decided to wait to report the misplaced keys until he talked to the operator that he relieved. The operator was unaware of the specific requirements contained in Regulatory Guide 5.62 pertaining to uncontrolled vital area keys.
Regulatory Guide 5.62 lists the following as an example of a Safeguards event required to be reponed within I hour: " Discovery of uncompensated and unaccounted for, lost, or stolen key cards, I.D. card blanks, keys, or any access device that could allow unauthorized or undetected access to protected areas, material access areas, l controlled access areas, or vital areas. Such events need not be reported within I hour if measures are taken '
within 10 minutes of the discovery of the loss to preclude the use of the lost or stolen device for gaining access to a controlled area and to ensure that the lost or stolen device has not been used in an unauthorized manner prior to completion of actions to prevent unauthorized use of the device."
At approximately 0600 hours0.00694 days <br />0.167 hours <br />9.920635e-4 weeks <br />2.283e-4 months <br /> on June 1,1999, the operator contacted the operator he relieved the previous shift.
He then realized that he had lost control of the key ring sometime prior to 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> on May 31,199?. He immediately proceeded to the control room and notified the Shift Supervisor of the missing keys. The Shift Supervisor asked to operator to search the office in which shift tumovers are conducted and to contact the other on-shift operators to see if they might have seen the keys. The Shift Supervisor then performed the initial contact of the Security Force Supervisor to report the missing keys. The Shift Supervisor left the control room s and proceeded to the Electrical Auxiliary Building office to question the operator regarding when the keys were noticed missing. It was at this time (0608 hours0.00704 days <br />0.169 hours <br />0.00101 weeks <br />2.31344e-4 months <br />) that the operator responded that the keys were noticed missing at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> on May 31,1999. The Shift Supervisor then contacted the Security Force Supervisor to notify him of the time that the keys were first noticed missing.
NRCIORM 366 (6-1998)
NRC FORM 366A , U.S. NUCI EAR REGULATORY CoMMISSIO$
(4 1998) .
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME m DOCKET LER NUMllER (6) PAGE (M South Texas, Unit 1 05000 498 I "
MP WEE 3 of 4 99 - S02 - 00 TEXT (Ifmore space is required, use additional copies ofNRC Form 366A) (17)
The Security Force Supervisor was notified of the missing vital area key at 0612 hours0.00708 days <br />0.17 hours <br />0.00101 weeks <br />2.32866e-4 months <br /> on June 1,1999. At 0615 hours0.00712 days <br />0.171 hours <br />0.00102 weeks <br />2.340075e-4 months <br /> the security force began implementing compensatory measures for the missing key. At 0622 hours0.0072 days <br />0.173 hours <br />0.00103 weeks <br />2.36671e-4 months <br /> all vital areas were posted, and vital door key cores change-out was completed at 1050 hours0.0122 days <br />0.292 hours <br />0.00174 weeks <br />3.99525e-4 months <br />, at which time compensatory posts we re secured.
At 0757 hours0.00876 days <br />0.21 hours <br />0.00125 weeks <br />2.880385e-4 months <br />, Eastern Time, the Nuclear Regulatory Commission notification was performed under requirements of 10CFR73.71(b).
At approximately 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br />, during walk-down of Equipment Clearance Order A-5828, a Mechanical Maintenance mechanic discovered the keys in the padlock attached to valve SD-0008C. He took control of the keys and returned them to the Unit i One Stop Shop. The keys were then turned over to the Unit 1 Shift Supervisor.
CAUSE OF EVENT The root cause of the event was lack of attention to detail to ensure control of the vital area key was maintained.
In addition, the operator's lack of knowledge pertaining to the consequences of a lost vital area security key resulted in his. failure to immediately report the keys missing.
ANALYSIS OF EVENT This event is reportable to the Nuclear Regulatory Commission under the requirement of 10CFR 73.71(b) because a vital area key was discovered missing and compensatory actions, to ensure that the lost key was not used in an unauthorized manner, were not instituted within ten minutes.
This event is not significant for the safe operation of the South Texas Project. The keys were left unattended inside a vital area, which has controlled access. The security computer system records were reviewed to verify i that the keys were not used in an unauthorized manner while missing. There were no security system alarms that could be attributed to the missing keys.
CORRECTIVE ACTIONS
- 1. The event was communicated to Operations personnel via night orders. This was completed on June 9, 1999.
l 2. Communicate with Operations the importance of maintaining control of vital area keys and the potential consequences of an uncontrolled key or security badge during Operations requalification training lessons learned. This will be completed by October 8,1999.
- 3. The importance of this event was discussed with the operator involved in accordance with the Constructive Discipline Program. This was completed on June 10,1999.
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NRC FORM 366A
- U.S. NUCLEAR REGULATORY COMMISSION $
(6-1993) .
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME(1) DOCKET LER NUMBER (6) PAGE (3)
South Texas, Unit 1 '
( 05000 498 I
~
- 2MP MEEE 4 of 4 99 - S02 - 00 TEXT (Ifmore space is required, use additional copies ofNRC Form 366A) (17)
ADDITIONAL INFORMATION There have been similar events in the past. Condition Report 97-17839 was a trend condition Report generated based upon the event code for Security Events, Non-security Force Error, and Key Control. Action 3 of Condition Report 97-17839 stated that Shift Supervisors reinforced the importance of traintaining control of the 10F10 security key in a crew briefing completed in January 1998. -
The independent verification performed when Equipment Clearance Order A-5828 was hung did not specifically require the lock to be verified as part of the Equipment Clearance Order, therefore, the failure to discover the
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l keys left in the lock during the independent verification is not considered a contributing factor to this event. 1 However, it should be considered a missed opportunity for mitigation of the event.
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