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| | issue date = 09/02/1988 | | | issue date = 09/02/1988 |
| | title = LER 88-006-00:on 880803,isolation of CO2 Fire Protection Sys,W/O Compensatory Action Occurred.Caused by Personnel Error.Appropriate Administrative Action Taken W/Individuals involved.W/880902 Ltr | | | title = LER 88-006-00:on 880803,isolation of CO2 Fire Protection Sys,W/O Compensatory Action Occurred.Caused by Personnel Error.Appropriate Administrative Action Taken W/Individuals involved.W/880902 Ltr |
| | author name = HODGE W M, SMITH W G | | | author name = Hodge W, Smith W |
| | author affiliation = INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG, MIDWEST ELECTRIC COOPERATIVE | | | author affiliation = INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG, MIDWEST ELECTRIC COOPERATIVE |
| | addressee name = | | | addressee name = |
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| =Text= | | =Text= |
| {{#Wiki_filter:ttACCELERATED DISTRIBUTION DEMONSTRATION SYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESSION NBR:8809080369 DOC.DATE: | | {{#Wiki_filter:ACCELERATED t |
| 88/09/02NOTARIZED-NODOCKETFACIL:50-315 DonaldC.CookNuclearPowerPlant,Unit1,Indiana&05000315.AUTH.NAMEAUTHORAFFILIATION HODGE,W.M. | | DISTRIBUTION DEMONSTRATION t SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS) |
| IndianaMichiganPowerCo.(formerly Indiana&MichiganEleSMITH,W.G.
| | ACCESSION NBR:8809080369 DOC.DATE: 88/09/02 NOTARIZED- NO DOCKET FACIL:50-315 Donald C. Cook Nuclear Power Plant, Unit 1, Indiana & 05000315 . |
| MidwestElectricCooperative RECIP.NAME RECIPIENT AFFILIATION
| | AUTH. NAME AUTHOR AFFILIATION HODGE,W.M. Indiana Michigan Power Co. (formerly Indiana & Michigan Ele SMITH,W.G. Midwest Electric Cooperative RECIP.NAME RECIPIENT AFFILIATION |
|
| |
|
| ==SUBJECT:== | | ==SUBJECT:== |
| LER88-006-00:on 880803,isolation ofC02fireprotection sys,w/ocompensatory actionduetopersonnel error.W/8ltr.DISTRIBUTION CODEIE22DCOPIESRECEIVED:LTR IENCLLSIZE:TITLE:50.73LicenseeEventReport(LER),IncidentRpt,etc.NOTES:RDRECIPIENT IDCODE/NAME PD3-1LASTANG,JINTERNAL:
| | LER 88-006-00:on 880803,isolation of C02 fire protection R sys,w/o compensatory action due to personnel error. |
| ACRSMICHELSON ACRSWYLIEAEOD/DSP/NASAEOD/DSP/TPAB DEDRONRR/DEST/CEB 8HNRR/DEST/ICSB 7NRR/DEST/MTB 9HNRR/DEST/RSB 8ENRR/DLPQ/HFB 10NRR/DOEA/EAB 11NRR/DREP/RPB 10NUDOCS-ABSTRACT RESTELFORD,J RES/DSIR/EIB EXTERNALEG&GWILLIAMSESHSTLOBBYWARDNRCPDRNSICMAYS,GCOPIESRECIPIENT LTTRENCLIDCODE/NAME 11PD3-1PD11111111111111111111111122111111ACRSMOELLERAEOD/DOAAEOD/DSP/ROAB ARM/DCTS/DAB NRR/DEST/ADS 7ENRR/DEST/ESB 8DNRR/DEST/MEB 9HNRR/DEST/PSB 8DNRR/DEST/SGB 8DNRR/DLPQ/QAB 10NRR/DREP/BAB 10NRR/J3RISJSIB 9AGFIL~02DS'IRDEPYRGN3FILE0144FORDBLDGHOY,A11LPDR11NSICHARRIS,J11COPIESLTTRENCL11221122111011111111111111111111111111DDS/ATOTALNUMBEROFCOPIESREQUIRED:
| | W/8 ltr. |
| LTTR46ENCL45 NRCFarm'AS(440)LICENSEEEYENTREPORT(LER)U.S.NUCLEARREOULATORY COMMISSION APPROVEDOMSNO.3160410IEXPIRES:4/31/44FACILITYNAME(1)D.C.CookNuclearPlant-UnitIDOCKETNVI44ER(2)os00o31PA1OF04soat>ono>rerotectlon ysem,souompensatory et>onDuetoPersonnel ErrorEVENTDATE(SILERNUMBER(4)REPORTDATE(7)OTHERFACILITIES INVOLVED(4)MONTHDAYYEARYEARgPSEOUENTIAL
| | DISTRIBUTION CODE IE22D COPIES RECEIVED:LTR I ENCL TITLE: 50.73 Licensee Event Report (LER), Incident Rpt, etc. |
| .%ISREVSIONNUMBERrSNUMEERMONTHOAYYEARFACILITYNAMESDOCKETNUMBER(s) 05000080388006000928805000OPERAT(NOMODE(4)POWERLEYEL09020A02(4)20.405(e) | | L SIZE: D NOTES: |
| (1((I)20ASS(~I(1)(4)20AOS(el(1)(SII 20AOS(eI(I)(Irl20AOS(eI(1)(el20AOS(cl50.34(cl(1) 50.34lc)(2) 50.73(el(2) | | RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD3-1 LA 1 1 PD3-1 PD 1 1 STANG,J 1 1 D |
| II)50.73(~)(2)(4)50.73le)(2)(IS)LICENSEECONTACTFORTHISLERl12)50.73(el(2)
| | INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DS P/NAS 1 1 AEOD/DSP/ROAB 2 2 AEOD/DSP/TPAB 1 1 ARM/DCTS/DAB 1 1 DEDRO 1 1 NRR/DEST/ADS 7E 1 0 NRR/DEST/CEB 8H 1 1 NRR/DEST/ESB 8D 1 1 NRR/DEST/ICSB 7 1 1 NRR/DEST/MEB 9H 1 1 NRR/DEST/MTB 9H 1 1 NRR/DEST/PSB 8D 1 1 NRR/DEST/RSB 8E 1 1 NRR/DEST/SGB 8D 1 1 NRR/DLPQ/HFB 10 1 1 NRR/DLPQ/QAB 10 1 1 NRR/DOEA/EAB 11 1 1 NRR/DREP/BAB 10 1 1 NRR/DREP/RPB 10 2 2 NRR/J3RISJSIB 9A 1 1 NUDOCS-ABSTRACT 1 1 G FIL~ |
| (Irl50.73(el(2)(r)50.73(e)(2)(rEI50.73(el(2)(rEII(A'I 50.73(el(2)(r(4)(5) 50.73(e)(2)(e)0THEREDUIREMKNTs oF10cFRg;(checfroneormoreoftheforrowinol (11)THISREPORTISSUBMITTED PURSVANTT73.71(4)73.71(clOTHER(SpecifyInAhrtrecthelowenrfInTert,HIICForm3BSAINAMEW.M.HodgeSecurityManagerTELKPHONK NUMSKRAREACODE616465-5901COMPLETEONELINKFOREACHCOMPONENT FAILUREDESCRIBED INTHISREPORT(13)CAUSESYS1'EMCOMPONENT MANUFAGTVRERTONPRDS(%a.5'AUSESYSTEMCOMPONENT MANUFAC.TURKREPORTASLTONPRDSL~%a%AWi5@Ievafrr'(s((LE SUPPLEMENTAL RKPORTEXPECTED(IelYESIffyer,completeEXPECTEDSUBMISSION DAFB)NOASSTRACTILImlttoIc00rpecee,EA,epproefmetery fifteentlngreapece typewrftten float)(14)EXPECTEDSUBMISSION OATS(15)MONTHOAYYEAROnAugust3,1988duringisolation/normalization oftheCardoxC02FireProtection Systemforthe4kvSwitchgear CableVault,personnel errorresultedintheisolation ofthefireprotection system,foraperiodof50minutes,withoutcompensatory actionasrequiredbyTechnical Specifi-cation3.7.9.3,actiona.Ithasbeenconcluded thatintheunlikelyeventofafire,personnel wouldhavebeenpromptlyawareofitspresenceandbeenable'tocontrolandextinguish thefirewithoutsignificant propogation orequipment damage.Topreventrecurrence appropriate administrative actionsweretakencon-cerningtheindividuals involved. | | DS'IR 02 1 1 1 |
| 8805'080369'30902 PDRADGCK050003i5SPDCNRCForm345(SS3) | | RES TELFORD,J 1 1 DEPY 1 RES/DSIR/EIB 1 1 RGN3 FILE 01 1 1 EXTERNAL EG&G WILLIAMSE S 4 4 FORD BLDG HOY,A 1 1 H ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC HARRIS,J 1 1 NSIC MAYS,G 1 1 D |
| NRCForm366A(6831LICENSEEENTREPORT(LER)TEXTCONTINUATION nU.S.NUCLEARREOULATORY COMMISSION APPROVEDOMSNO.31SO&104EXPIRES:8/31/BSFACILITYNAME(11D.C.CookNuclearPlant-Unit1DOCKETNUMBER(21LERNUMBER(61YEARg8'SOVENTIAL
| | S |
| ~....INVMBBRREVISIONNUMBERPACE(31TECT//F'/4//ro
| | / |
| <<>>ce/4iso//Br/I>>Bd/Eor>>/HRC | | A TOTAL NUMBER OF COPIES REQUIRED: LTTR 46 ENCL 45 |
| %%dnrr3(ISA3/(IT(050003]88-0060002QF0onditions PriorToccurrence Unit1operating at90percentreactorthermalpower.DescritionofEventOnAugust3,1988,duringisolation/normalization ofthecardoxC02fireprotection system(EIIS/KQ) forthe4kvswitchgear cablevault,personnel errorresultedintheisolation ofthefireprotection system,foraperiodof50minutes,withoutcompensatory measuresasrequiredbyTechnical Specification 3.7.9.3actiona.Thesequenceofeventswereasfollows.Atapproximately 0745hoursaplantsecurityofficerwasdispatched toisolatetheCardoxC02systemforthe4kvswitchgear roomareatofacilitate routinemaintenance activities. | | |
| [NOTE-Thisisolation isnormallyaccomplished by:1)isolating themaster"normal/isolation" switch(EIIS/KQ-HS) fortheentire4kvarea;2)initiating firewatchpatrolsatafrequency ofonceevery30minutes;and3)loggingtheisolation of'involved switchesonthe"CardoxActivityLog"].At0747hours,thesecurityofficerattempted toisolatethemasterswitchbutnoteditwasinoperable. | | NRC Farm 'AS U.S. NUCLEAR REOULATORY COMMISSION (440) |
| Thisrequiredthesecurityofficertoisolate4individual switches(EIIS/KQ-,HS),
| | APPROVED OMS NO. 3160410I LICENSEE EYENT REPORT (LER) EXPIRES: 4/31/44 FACILITY NAME (1) DOCKET NVI44ER (2) PA D. C. Cook Nuclear Plant - Unit I os 0 0o31 1 OF 0 4 so at>on o >re rotectlon ys em, s ou ompensatory et>on Due to Personnel Error EVENT DATE (SI LER NUMBER (4) REPORT DATE (7) OTHER FACILITIES INVOLVED (4) |
| threeswitcheslocatedadjacenttothemasterswitchoutsidethe4kventrance, andoneswitchinsidethe4kvarea,attheentrancetothecablevault.Following theisolation, thesecurityofficerlogged"Unit14kv-4switches",
| | SEOUENTIAL .%IS REVSION MONTH OAY YEAR FACILITYNAMES DOCKET NUMBER(s) |
| ontheCardoxSwitchActivityLog.Whiletheproperswitcheswereisolated, andcompensatory firewatchcoverageinitiated, thesecurityofficerviolatedSecurityPostOrderSP0.016(CardoxSwitchControl)inthatfourentriesshouldhavebeenloggedonthetrackingsheettocorrespond tothefourswitchesthatwere'repositioned fortheisolation ofthearea.At-0828hours,following completion ofMaintenance activities inthearea,securitywasrequested tonormalize theCardoxSystems.SinceSecuritypostrotations hadtakenplaceadifferent securityofficerresponded totherequest.Uponarrivalatthe4kvswitchgear roomthesecondofficerreferredtotheCardoxswitchtrackingsheettodetermine whichswitcheshadbeenisolated.
| | MONTH DAY YEAR YEAR gP NUMBER rS NUMEER 0 5 0 0 0 08 03 8 8 0 0 6 00 0 9 288 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSVANT T0 THE REDUIREMKNTs oF 10 cFR g; (checfr one or more of the forrowinol (11) |
| Theofficernotedoneentry("Unit14kv-4switches"),
| | OP ERAT(NO MODE (4) 20A02(4) 20AOS(cl 50.73(el(2) (Irl 73.71 (4) |
| andnormalized threeswitcheslocatedoutsidethe4kvarea,adjacenttothemasterswitch.Theofficerfailedtoenterthe4kvareatonormalize theswitchgear cablevaultcardoxswitch,andfailedtorecognize hehadonlynormalized threeswitches.
| | POWER 20.405(e) (1((I) 50.34(cl(1) 50.73(e l(2)(r) 73.71(cl LEYEL le)(2) 0 9 0 20 ASS( ~ I (1) (4) 50.34lc)(2) 50.73(e) (2)(rEI OTHER (Specify In Ahrtrect helow enrf In Tert, HIIC Form 20AOS(el(1)(SII 50.73(el(2) II) 50.73(el(2)(rEII(A'I 3BSAI 20AOS (e I (I) (Irl 50.73( ~ )(2)(4) 50.73(el(2)(r(4)(5) 20AOS(e I (1)(el 50.73 (IS) 50.73(e) (2)(e) |
| Firewatchcoveragewasdiscontinued atthistime(0828Hrs).NRCFORM3BBA(8831*U.S.GPO:I SSS0.624538/455 NRCForm366A(64)3)LICENSEEENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION APPROVEOOMBNO.3)60M)04EXPIRES:8/31/88FACILITYNAME(1)D.C.CookNuclearPlant-Unit1TEXT/6'/IKBBNMBB)1tor)U(od, IIBBaES/orN/NRC Furr3664'4)(17)OOCKETNUMBER(2)YEAR31588LERNUMBER(6)~SEGUENTIAL NUMBER006>re'EVISION NUMBER-00PAGE(3)03o"04At0918hours,thesamesecondsecurityofficerresponded toanunrelated requesttoreisolate the4kvarea.Whentheofficerreportedtheisolation tothecontrolroom,hewasremindedtoisolatetheswitchinsidethe4kvareabycontrolroompersonnel.
| | LICENSEE CONTACT FOR THIS LER l12) |
| Atthistimethesecurityofficerdiscovered thedeficiency andfirewatch coveragewasimmediately reestablished.
| | NAME TELKPHONK NUMSKR W. M. Hodge AREA CODE Security Manager 616 465 -59 01 COMPLETE ONE LINK FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13) |
| Theswitchgear cablevaultareaCardoxSystemhadbeenisolatedfrom0828hoursto0918hours(50minutes),
| | CAUSE SYS1'EM COMPONENT MANUFAG TVRER TO NPRDS ( %a .5 |
| withoutcompensatory firewatchcoverage.
| | 'AUSE SYSTEM COMPONENT MANUFAC. |
| CauseOfTheEventThiseventwastheresultof2personnel errorsinvolving thefailuretoproperlycomplywiththeapprovedprocedure:
| | TURKR EPORTASL TO NPRDS L~% |
| 1)Thesecurityofficerinitially isolating theCardoxSystemforentryintothe4kvareafailedtoproperlylogtheisolation ofeachindividual areaswitchturned(Security PostOrderSP0.016requireseachswitchturnedtobeloggedseparately ontheswitchactivitylog,'thesecurityofficermadeoneentryandnotedthatfourswitcheshadbeenturned);and,2)thesecurityofficernormalizing theCardoxSystemsreferenced theswitchactivitylogandproperlyreadtheentryasfourswitches, howeveronlyrepositioned (normalizing) threeswitches. | | a%AWi 5 @Ievafrr'(s((LE SUPPLEMENTAL RKPORT EXPECTED (Iel MONTH OAY YEAR EXPECTED SUBMISSION OATS (15) |
| Thesecurityofficernormalizing theCardoxSystemserroneously countedtheswitcheshehadrepositioned.
| | YES Iffyer, complete EXPECTED SUBMISSION DA FB) NO ASSTRACT ILImlt to Ic00 rpecee, EA, epproefmetery fifteen tlngreapece typewrftten float) (14) |
| AnalsisOfTheEventTheisolation oftheswitchgear cablevaultCardoxSystemwithoutcompensatory firewatchcoverage, wasinviolation ofTechnical Specification 3.7.9.3actiona,andisreportable under10CFR50.73(a)(2)(i)(B).Ithasbeenconcluded thatintheunlikelyeventofafire,personnel wouldhavebeenpromptlyawareofitspresenceandbeenabletocontrolandextinguish thefirewithoutsignificant propagation orequipment damage.Thisconclusion isbasedonthefollowing:
| | On August 3, 1988 during isolation/normalization of the Cardox C02 Fire Protection System for the 4kv Switchgear Cable Vault, personnel error resulted in the isolation of the fir e protection system, for a period of 50 minutes, without compensatory action as required by Technical Specifi-cation 3.7.9.3, action a. |
| 1)therelatively lowfixedcombustible loadwithintheareainvolved(33,552BTU'spersquarefoot..for afiredurationoflessthan30minutes); | | It has been concluded that in the unlikely event of a fire, personnel would have been promptly aware of its presence and been able 'to control and extinguish the fire without significant propogation or equipment damage. |
| 2)thephysicalandadministrative limitsontheintroduction oftransient combustibles (onlyanegligible amountofcombustibles werepresentintheinvolvedareaforthedurationoftheevent);3)operableearlywarningfiredetection systems(consisting ofbothionization andinfrareddetectors), | | To prevent recurrence appropriate administrative actions were taken con-cerning the individuals involved. |
| and4)theexistence ofatrainedon-shiftfirebrigade.Basedontheabove,thiseventisnotconsidered tohavecreatedanysignificant safetyconcernanddidnotconstitute anunreviewed
| | 8805'080369'30902 PDR ADGCK 050003i5 S PDC NRC Form 345 (SS3) |
| 'safetyquestionasdefinedin10CFR50.59,nordiditcreateasignificant hazardtothehealthandsafetyofthegeneralpublic.NRCFORM3BBA(64)3)*U.S.GPO:1986.0 624538/465 NRCForm366A(943)LICENSEEENTREPORT(LER)TEXTCONTINUIONU.S.NUCLEARREGULATORY COMMISSION APPROVEOOMSNO.3150W104EXPIRES:8/3(/88FACILITYNAME(I)D.C.CookNuclearPlant-Unit1OOCKETNUMBER(2)LERNUMBER(6)VEAR'.v<:@'EQUENTIAL 4$NUMBERNOREVISIONNUMBERPAGE(3)TEXTCF/RoroEPBoo/rFBBUSBI/Irooa//I/ooo/NRC | | |
| %%drrn3/)//A'/(17)050003]880060004QF04Corrective ActionTopreventrecurrence, appropriate administrative actionsweretakenconcerning theindividuals involved. | | NRC Form 366A U.S. NUCLEAR REOULATORY COMMISSION (6831 LICENSEE ENT REPORT (LER) TEXT CONTINUATION APPROVED OMS NO. 31SO&104 n |
| Althoughthefirstsecurityofficerfailedtofollowprocedural guidanceinloggingoftherepositioned
| | EXPIR ES: 8/31/BS FACILITY NAME (11 DOCKET NUMBER (21 LER NUMBER (61 PACE (31 D. C. Cook Nuclear Plant Unit 1 YEAR |
| : switches, theofficerdidprovidesufficient information thatthesecondsecurityofficershouldhaverecognized thecondition oftheaffectedswitches.
| | ~ |
| Thesecondofficersimplyfailedtocountthenumberofswitchesherepositioned/normalized.
| | g8'SOVENTIAL |
| Ithasbeenconcluded thatadequateprocedural instruction currently exists.Inconsideration offormerLER315/88-005-00 therehasbeenindividual identification numbersandisolation zonedescriptions placedoneachcardoxcontrolswitch.Thesenumbersmaybeusedasanoperational aidtoassuretheproperswitchorswitchesaremanipulated.
| | .... I NVMBBR REVISION NUMBER 0 5 0 0 0 3 ] 88 0 0 6 0 0 0 2 QF 0 TECT //F'/4//ro <<>>ce /4 iso//Br/ I>>B d/Eor>>/HRC %%dnrr 3(ISA3/ (IT( |
| Installation ofthenumbersandisolation zoneinformation wascompleted onSeptember 1,1988.FailedComonentIdentification Notapplicable | | onditions Prior To ccurrence Unit 1 operating at 90 percent reactor thermal power. |
| -Nocomponents failedduringthecourseofthisevent.PreviousSimilarEvents50-315/88.-005 50-315/85-008,-020 50316/84009F022F02750-316/83-048,-060 50-315/83-022,-028,-034,-094,-114 50-316/82-054,-058,-062,-076,-084 50315/82037F044F045F049F068F081'F082F108NRCFO/IMSBBA(983)*U.S.GPO:1986 0.824538/488 IndianaMichigaPowerCotnpanyCookNuclearPlaniP.O.Box458Bridgman, Ml491066164655901INDIANANICHIGANPOWERSeptember 2,1988UnitedStatesNuclearRegulatory Commission DocumentControlDeskWashington, D.C.20555Operating LicenseDPR-58DocketNo.50-315DocumentControlManager:Inaccordance withthecriteriaestablished by10CFR50.73entitledLicenseeEventReortinSstem,thefollowing reportisbeingsubmitted:
| | Descri tion of Event On August 3, 1988, during isolation/normalization of the cardox C02 fire protection system (EIIS/KQ) for the 4kv switchgear cable vault, personnel error resulted in the isolation of the fire protection system, for a period of 50 minutes, without compensatory measures as required by Technical Specification 3.7.9.3 action a. |
| 88-006-00 Sincerely, u,~gPlantManagerWGS:clwAttachment cc:D.H.Williams, Jr.A.B.Davis,RegionIIIM.P.AlexichP.A.BarrettJ.E.BorggrenR.F.KroegerNRCResidentInspector J.F.Stang,NRCR.C.CallenG.Charnoff, Esq.DottieSherman,ANILibraryD.HahnINPOPNSRCA.A.BlindS.J.Brewer/B. | | The sequence of events were as follows. At approximately 0745 hours a plant security officer was dispatched to isolate the Cardox C02 system for the 4kv switchgear room area to facilitate routine maintenance activities. [NOTE This isolation is normally accomplished by: 1) isolating the master "normal/isolation" switch (EIIS/KQ-HS) for the entire 4kv area; 2) initiating fire watch patrols at a frequency of once every 30 minutes; and 3) logging the isolation of'involved switches on the "Cardox Activity Log"]. At 0747 hours, the security officer attempted to isolate the master switch but noted it was inoperable. |
| P.Lauzau}} | | officer to isolate 4 individual switches (EIIS/KQ-,HS), three4kv This required the security switches located adjacent to the master switch outside the entrance, and one switch inside the 4kv area, at the entrance to the cable vault. Following the isolation, the security officer logged "Unit 1 4kv 4 switches", on the Cardox Switch Activity Log. While the proper switches were isolated, and compensatory fire watch coverage initiated, the security Control) officer violated Security Post Order SP0.016 (Cardox Switch in that four entries should have been logged on the tracking sheet to correspond to the four switches that were 'repositioned for the isolation of the area. |
| | At- 0828 hours, following completion of Maintenance activities in the area, security was requested to normalize the Cardox Systems. |
| | Since Security post rotations had taken place a different security officer responded to the request. Upon arrival the at the 4kv switchgear room the second officer referred to Cardox switch tracking sheet to determine which switches had been isolated. The officer noted one entry ("Unit 1 4kv 4 switches"), and normalized three switches located outside the 4kv area, adjacent to the master switch. The officer failed to enter the 4kv area to normalize the switchgear cable vault cardox switch, and failed to recognize he had only normalized three switches. Fire watch coverage was discontinued at this time (0828 Hrs). |
| | NRC FORM 3BBA *U.S.GPO:I SSS 0.624 538/455 (8831 |
| | |
| | NRC Form 366A U.S. NUCLEAR REGULATORY COMMISSION (64)3) |
| | LICENSEE ENT REPORT (LER) TEXT CONTINUATION APPROVEO OMB NO. 3) 60M)04 EXPIRES: 8/31/88 FACILITYNAME (1) OOCKET NUMBER (2) |
| | LER NUMBER (6) PAGE (3) |
| | D. C. Cook Nuclear Plant Unit 1 YEAR ~ SEGUENTIAL >re'EVISION NUMBER NUMBER 3 1 5 8 8 0 0 6 0 0 0 3o" 0 4 TEXT /6'/IKBB NMBB )1 tor)U(od, IIBB aES/orN/NRC Furr 3664'4) (17) |
| | At 0918 hours, the same second security officer responded to an unrelated request to reisolate the 4kv area. When the officer reported the isolation to the control room, he was reminded to isolate the switch inside the 4kv area by control room personnel. |
| | At this time the security officer discovered the deficiency and firewatch coverage was immediately reestablished. The switchgear cable vault area Cardox System had been isolated from 0828 hours to 0918 hours (50 minutes), without compensatory fire watch coverage. |
| | Cause Of The Event This event was the result of 2 personnel errors involving the failure to properly comply with the approved procedure: 1) The security officer initially isolating the Cardox System for entry into the 4kv area failed to properly log the isolation of each individual area switch turned (Security Post Order SP0.016 requires each switch turned to be logged separately on the switch activity log, 'the security officer made one entry and noted that normalizing four switches had been turned); and, 2) the security officer the Cardox Systems referenced the switch activity log and properly read the entry as four switches, however only repositioned (normalizing) three switches. The security officer normalizing the Cardox Systems erroneously counted the switches he had repositioned. |
| | Anal sis Of The Event The isolation of the switchgear cable vault Cardox System without compensatory fire watch coverage, was in violation of Technical Specification 3.7.9.3 action a, and is reportable under 10 CFR 50.73 (a) (2) (i) (B). |
| | It has been concluded that in the unlikely event of a fire, personnel would have been promptly aware of its presence and been able to control and extinguish the fire without significant propagation or equipment damage. This conclusion is based on the following: 1) the relatively low fixed combustible load within of the area involved (33,552 BTU's per square foot..for a fire duration less than 30 minutes); 2) the physical and administrative limits on the introduction of transient combustibles (only a negligible amount of combustibles were present in the involved area for the duration of the event); 3) operable early warning fire detection and systems (consisting of both ionization and infrared detectors), |
| | : 4) the existence of a trained on-shift fire brigade. |
| | Based on the above, this event is not considered to have created any significant safety concern and did not constitute an unreviewed |
| | 'safety question as defined in 10 CFR 50.59, nor did of the it create a public. |
| | significant hazard to the health and safety general NRC FORM 3BBA *U.S.GPO:1986.0 624 538/465 (64)3) |
| | |
| | NRC Form 366A U.S. NUCLEAR REGULATORY COMMISSION (943) |
| | LICENSEE ENT REPORT (LER) TEXT CONTINU ION APPROVEO OMS NO. 3150W104 EXPIRES: 8/3(/88 FACILITYNAME (I) OOCKET NUMBER (2) LER NUMBER (6) PAGE (3) |
| | VEAR '.v<:@'EQUENTIAL NO REVISION Unit 4$ NUMBER NUMBER D. C. Cook Nuclear Plant 1 0 5 0 0 0 3 ] 8 8 0 0 6 0 0 0 4 QF 0 4 TEXT CF/Roro EPBoo /r FBBUSBI/ Iroo a //I/ooo/NRC %%drrn 3/)//A'/ (17) |
| | Corrective Action To prevent recurrence, appropriate administrative actions were taken concerning the individuals involved. Although the first security officer failed to follow procedural guidance in logging of the repositioned switches, the officer did provide sufficient information that the second security officer should have recognized the condition of the affected switches. The second officer simply failed to count the number of switches he repositioned/normalized. |
| | It has been concluded that adequate procedural instruction currently exists. |
| | In consideration of former LER 315/88-005-00 there has been individual identification numbers and isolation zone descriptions placed on each cardox control switch. These numbers may be used as an operational aid to assure the proper switch or switches are manipulated. Installation of the numbers and isolation zone information was completed on September 1, 1988. |
| | Failed Com onent Identification Not applicable No components failed during the course of this event. |
| | Previous Similar Events 50-315/88.-005 50-315/85-008,-020 50 316/84 009F 022F 027 50-316/83-048,-060 50-315/83-022,-028,-034,-094,-114 50-316/82-054,-058,-062,-076,-084 50 315/82 037F 044F 045F 049F 068F 081'F 082F 108 NRC FO/IM SBBA *U.S.GPO:1986 0.824 538/488 (983) |
| | |
| | Indiana Michiga Power Cotnpany Cook Nuclear Plani P.O. Box 458 Bridgman, Ml 49106 616 465 5901 INDIANA NICHIGAN POWER September 2, 1988 United States Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555 Operating License DPR-58 Docket No. 50-315 Document Control Manager: |
| | In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ortin S stem, the following report is being submitted: |
| | 88-006-00 Sincerely, u,~g Plant Manager WGS:clw Attachment cc: D. H. Williams, Jr. |
| | A. B. Davis, Region M. P. Alexich III P. A. Barrett J. E. Borggren R. F. Kroeger NRC Resident Inspector J. F. Stang, NRC R. C. Callen G. Charnoff, Esq. |
| | Dottie Sherman, ANI Library D. Hahn INPO PNSRC A. A. Blind S. J. Brewer/B. P. Lauzau}} |
Similar Documents at Cook |
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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17335A5641999-10-18018 October 1999
LER 99-024-00:on 990708,literal TS Requirements Were Not Met by Accumlator Valve Surveillance.Caused by Misjudgement Made in Conversion from Initial DC Cook TS to W Std Ts.Submitted License Amend Request.With 991018 Ltr
ML17335A5531999-10-0707 October 1999
LER 99-023-00:on 990907,inadequate TS Surveillance Testing of ESW Pump ESF Response Time Noted.Caused by Inadequate Understanding of Plant Design Basis.Surveillance Tests Will Be Revised & Implemented
ML17326A1291999-09-17017 September 1999
LER 99-022-00:on 990609,electrical Bus Degraded Voltage Setpoints Too Low for Safety Related Loads,Was Discovered. Caused by Lack of Understanding of Design of Plant.No Immediate Corrective Actions Necessary
ML17326A1121999-08-27027 August 1999
LER 99-021-00:on 990728,determined That GL 96-01 Test Requirements Were Not Met in Surveillance Tests.Caused by Failure to Understand Full Extent of GL Requirements. Surveillance Procedures Will Be Revised or Developed
ML17326A1011999-08-26026 August 1999
LER 99-020-00:on 990727,EDGs Were Declared Inoperable.Caused by Inadequate Protection of Air Intake,Exhaust & Room Ventilation Structures from Tornado Missile Hazards. Implemented Compensatory Measures in Form of ACs
ML17326A0911999-08-16016 August 1999
LER 99-019-00:on 990716,noted Victoreen Containment Hrrms Not Environmentally Qualified to Withstand post-LOCA Conditions.Caused by Inadequate Design Control.Reviewing Options to Support Hrrms Operability in Modes 1-4
ML17326A0771999-08-0404 August 1999
LER 98-029-01:on 980422,noted That Fuel Handling Area Ventilation Sys Was Inoperable.Caused by Original Design Deficiency.Radiological Analysis for Spent Fuel Handling Accidents in Auxiliary Bldg Will Be Redone by 990830
ML17326A0741999-07-29029 July 1999
LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves
ML17326A0661999-07-26026 July 1999
LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr
ML17326A0651999-07-22022 July 1999
LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis
ML17326A0491999-07-13013 July 1999
LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr
ML17326A0331999-07-0101 July 1999
LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written
ML17326A0151999-06-18018 June 1999
LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified
ML17325B6311999-06-0101 June 1999
LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions
ML17325B6421999-06-0101 June 1999
LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed
ML17325B6351999-05-28028 May 1999
LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions
ML17265A8231999-05-24024 May 1999
LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made
ML17325B6001999-05-20020 May 1999
LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed
ML17325B5861999-05-10010 May 1999
LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised
ML17325B5811999-05-0404 May 1999
LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared
ML17325B5771999-05-0303 May 1999
LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design
ML17325B5581999-04-16016 April 1999
LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold
ML17325B5471999-04-12012 April 1999
LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation
ML17325B5321999-04-0707 April 1999
LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate
ML17325B5161999-04-0101 April 1999
LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures
ML17325B5221999-03-29029 March 1999
LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing
ML17325B4801999-03-18018 March 1999
LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling
ML17325B4741999-03-18018 March 1999
LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed
ML17325B4571999-02-24024 February 1999
LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors
ML17335A5171999-02-11011 February 1999
LER 99-002-00:on 990112,determined That RCS Pressurizer PORVs Had Not Been Tested,Per Ts.Caused by Inadequate Scheduling Controls Allowing Personnel Error.Surveillance Procedure Was Completed & Updated LER Will Be Submitted
ML17335A5141999-02-10010 February 1999
LER 99-001-00:on 990106,noted That GE Hfa Relays Installed in EDGs May Not Meet Seismic Qualification.Caused by Operating Experience Info Incorrectly Dispositioned in 1985. Updated LER Will Be Submitted by 990405
ML17335A5011999-02-0101 February 1999
LER 98-060-00:on 981231,identified That Rt Sys Response Time Testing Did Not Comply with TS Definition.Caused by Inadequate Procedures.Corrective Actions Will Be Developed & Update to LER Will Be Submitted by 990415.With 990201 Ltr
ML17335A4951999-01-29029 January 1999
LER 98-059-00:on 981230,interim LER -single Failure in Containment Spray Sys Could Result in Containment Spray Ph Outside Design Occurred.Investigation Into Condition Continuing.Update Will Be Submitted by 990514 Ltr
ML17335A4961999-01-27027 January 1999
LER 98-057-00:on 981228,discovered That AFW Valves Were Not Tested IAW Inservice Testing Program.Caused by Failure to Recognize Design Bases Features Re Afws by Personnel. Updated LER Will Be Submittted by 990415.With 990127 Ltr
ML17335A4921999-01-19019 January 1999
LER 98-052-01:on 981128,no Analysis for NSR Sc Manual Loader for Tdafwp Could Be Found in Original Design.Cause Due to All Failure Modes Not Considered When Compressed Air Sys Originally Designed.Performed Review of Components
ML17335A4721999-01-0606 January 1999
LER 98-055-00:on 981207,potential for Condition Outside of Design Bases for Rod Control Sys Was Noted.Caused by Calibration Error Coupled with Single Rod Failure.Condition Rept Investigation Is Ongoing
ML17335A4691999-01-0606 January 1999
LER 98-056-00:on 981211,hot Leg Nozzle Gaps Resulted in Plant Being in Unanalyzed Condition.Analyses Are Being Performed by W to Resolve Problem.Updated LER Will Be Submitted by 990211.With 990106 Ltr
ML17335A4661999-01-0505 January 1999
LER 98-049-00:on 981020,emergency Boron Injection Flow Path Was Inoperable.Caused by Original Design Deficiency. Engineering Evaluation of Event Is Continuing
ML17335A4631999-01-0404 January 1999
LER 98-054-00:on 981202,discovered That at Least One MSSV Had Not Been Reset as Required by Ts.Engineering Is Continuing Review of Extent of Condition for Event.Updated LER Will Be Submitted by 990129.With 990104 Ltr
ML17335A4481998-12-30030 December 1998
LER 98-053-00:on 981130,discovered Use of Inoperable Substitute Subcooling Margin Monitor.Caused by Condition Existing Since Installation of Plant Process Computer in 1992.Updated LER Will Be Submitted.With 981230 Ltr
ML17335A4581998-12-28028 December 1998
LER 98-052-00:on 981128,turbine Driven AFW Pump Speed Controller Failure Mode Occurred.Caused Because Not All Failure Modes Were Considered When Compressed Air Sys Was Originally Designed.Verified Current Design Change Process
ML17335A4281998-12-22022 December 1998
LER 98-051-00:on 981122,reactor Trip Signal from Manual Safety Injection Not Verified as Required by TS Surveillance,Was Discovered.Maintenance Currently Evaluating Significance & Cause of Event
ML17335A4111998-12-17017 December 1998
LER 98-047-00:on 981117,potential for Increase Leakage from Reactor Coolant Pump Seals Was Identified.Util Is Working with W to Resolve Issue.Current Expectations Are to Submit Update to LER by 990215.With 981217 Ltr
ML17335A4141998-12-16016 December 1998
LER 98-058-00:on 981216,postulated High Line Break Could Result in Condition Outside Design Bases for AF Occurred. Caused by Deficiencies Associated with Administration of HELB Program.Analysis of AF Will Be Completed by 990122
ML17335A4181998-12-16016 December 1998
LER 98-050-00:on 980814,ancillary Equipment Installed in Ice Condenser Was Not Designed to Withstand Design Basis Accident/Earthquake Loads.Caused by Lack of Established Design Criteria.Developed Design Criteria
ML17335A3871998-12-11011 December 1998
LER 98-031-01:on 980610,potential Common Mode Failure of RHR Pumps Were Noted.Caused by Inaccurate Values.Accurate Miniflow Numbers Have Been Determined by Flow Testing
ML17335A3821998-12-0808 December 1998
LER 98-039-01 Re EOP Step Conflicts with Small Break LOCA Analysis.Ler 98-039-00 Has Been Canceled.With 981208 Ltr
ML17335A3781998-12-0707 December 1998
LER 98-007-00:on 981106,high Energy Line Break Effects in Auxiliary FW Sys Was Noted.Cause of Event Is Under Investigation & Will Be Completed by 990220.Updated LER Will Be Submitted by 990310.With 981207 Ltr
ML17335A3771998-12-0303 December 1998
LER 98-046-00:on 981103,determined That Afs Was Unable to Meet Design Flow Requirements During Special Test.Caused by Failure to Consider All Aspects of Sys Operation in Design of Suction Basket Strainers.Sys Will Be Redesigned
ML17335A3741998-12-0202 December 1998
LER 97-011-02:on 970822,operation Was Noted Outside Design Bases for ECCS & CSP for Switchover to Recirculation Sump Suction.Caused by Ineffective Change Mgt.Revised Procedure for Switchover 01(02) Ohp 4023.ES-1.3
1999-09-17
[Table view]
Category:RO)
MONTHYEARML17335A5641999-10-18018 October 1999
LER 99-024-00:on 990708,literal TS Requirements Were Not Met by Accumlator Valve Surveillance.Caused by Misjudgement Made in Conversion from Initial DC Cook TS to W Std Ts.Submitted License Amend Request.With 991018 Ltr
ML17335A5531999-10-0707 October 1999
LER 99-023-00:on 990907,inadequate TS Surveillance Testing of ESW Pump ESF Response Time Noted.Caused by Inadequate Understanding of Plant Design Basis.Surveillance Tests Will Be Revised & Implemented
ML17326A1291999-09-17017 September 1999
LER 99-022-00:on 990609,electrical Bus Degraded Voltage Setpoints Too Low for Safety Related Loads,Was Discovered. Caused by Lack of Understanding of Design of Plant.No Immediate Corrective Actions Necessary
ML17326A1121999-08-27027 August 1999
LER 99-021-00:on 990728,determined That GL 96-01 Test Requirements Were Not Met in Surveillance Tests.Caused by Failure to Understand Full Extent of GL Requirements. Surveillance Procedures Will Be Revised or Developed
ML17326A1011999-08-26026 August 1999
LER 99-020-00:on 990727,EDGs Were Declared Inoperable.Caused by Inadequate Protection of Air Intake,Exhaust & Room Ventilation Structures from Tornado Missile Hazards. Implemented Compensatory Measures in Form of ACs
ML17326A0911999-08-16016 August 1999
LER 99-019-00:on 990716,noted Victoreen Containment Hrrms Not Environmentally Qualified to Withstand post-LOCA Conditions.Caused by Inadequate Design Control.Reviewing Options to Support Hrrms Operability in Modes 1-4
ML17326A0771999-08-0404 August 1999
LER 98-029-01:on 980422,noted That Fuel Handling Area Ventilation Sys Was Inoperable.Caused by Original Design Deficiency.Radiological Analysis for Spent Fuel Handling Accidents in Auxiliary Bldg Will Be Redone by 990830
ML17326A0741999-07-29029 July 1999
LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves
ML17326A0661999-07-26026 July 1999
LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr
ML17326A0651999-07-22022 July 1999
LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis
ML17326A0491999-07-13013 July 1999
LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr
ML17326A0331999-07-0101 July 1999
LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written
ML17326A0151999-06-18018 June 1999
LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified
ML17325B6311999-06-0101 June 1999
LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions
ML17325B6421999-06-0101 June 1999
LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed
ML17325B6351999-05-28028 May 1999
LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions
ML17265A8231999-05-24024 May 1999
LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made
ML17325B6001999-05-20020 May 1999
LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed
ML17325B5861999-05-10010 May 1999
LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised
ML17325B5811999-05-0404 May 1999
LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared
ML17325B5771999-05-0303 May 1999
LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design
ML17325B5581999-04-16016 April 1999
LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold
ML17325B5471999-04-12012 April 1999
LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation
ML17325B5321999-04-0707 April 1999
LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate
ML17325B5161999-04-0101 April 1999
LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures
ML17325B5221999-03-29029 March 1999
LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing
ML17325B4801999-03-18018 March 1999
LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling
ML17325B4741999-03-18018 March 1999
LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed
ML17325B4571999-02-24024 February 1999
LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors
ML17335A5171999-02-11011 February 1999
LER 99-002-00:on 990112,determined That RCS Pressurizer PORVs Had Not Been Tested,Per Ts.Caused by Inadequate Scheduling Controls Allowing Personnel Error.Surveillance Procedure Was Completed & Updated LER Will Be Submitted
ML17335A5141999-02-10010 February 1999
LER 99-001-00:on 990106,noted That GE Hfa Relays Installed in EDGs May Not Meet Seismic Qualification.Caused by Operating Experience Info Incorrectly Dispositioned in 1985. Updated LER Will Be Submitted by 990405
ML17335A5011999-02-0101 February 1999
LER 98-060-00:on 981231,identified That Rt Sys Response Time Testing Did Not Comply with TS Definition.Caused by Inadequate Procedures.Corrective Actions Will Be Developed & Update to LER Will Be Submitted by 990415.With 990201 Ltr
ML17335A4951999-01-29029 January 1999
LER 98-059-00:on 981230,interim LER -single Failure in Containment Spray Sys Could Result in Containment Spray Ph Outside Design Occurred.Investigation Into Condition Continuing.Update Will Be Submitted by 990514 Ltr
ML17335A4961999-01-27027 January 1999
LER 98-057-00:on 981228,discovered That AFW Valves Were Not Tested IAW Inservice Testing Program.Caused by Failure to Recognize Design Bases Features Re Afws by Personnel. Updated LER Will Be Submittted by 990415.With 990127 Ltr
ML17335A4921999-01-19019 January 1999
LER 98-052-01:on 981128,no Analysis for NSR Sc Manual Loader for Tdafwp Could Be Found in Original Design.Cause Due to All Failure Modes Not Considered When Compressed Air Sys Originally Designed.Performed Review of Components
ML17335A4721999-01-0606 January 1999
LER 98-055-00:on 981207,potential for Condition Outside of Design Bases for Rod Control Sys Was Noted.Caused by Calibration Error Coupled with Single Rod Failure.Condition Rept Investigation Is Ongoing
ML17335A4691999-01-0606 January 1999
LER 98-056-00:on 981211,hot Leg Nozzle Gaps Resulted in Plant Being in Unanalyzed Condition.Analyses Are Being Performed by W to Resolve Problem.Updated LER Will Be Submitted by 990211.With 990106 Ltr
ML17335A4661999-01-0505 January 1999
LER 98-049-00:on 981020,emergency Boron Injection Flow Path Was Inoperable.Caused by Original Design Deficiency. Engineering Evaluation of Event Is Continuing
ML17335A4631999-01-0404 January 1999
LER 98-054-00:on 981202,discovered That at Least One MSSV Had Not Been Reset as Required by Ts.Engineering Is Continuing Review of Extent of Condition for Event.Updated LER Will Be Submitted by 990129.With 990104 Ltr
ML17335A4481998-12-30030 December 1998
LER 98-053-00:on 981130,discovered Use of Inoperable Substitute Subcooling Margin Monitor.Caused by Condition Existing Since Installation of Plant Process Computer in 1992.Updated LER Will Be Submitted.With 981230 Ltr
ML17335A4581998-12-28028 December 1998
LER 98-052-00:on 981128,turbine Driven AFW Pump Speed Controller Failure Mode Occurred.Caused Because Not All Failure Modes Were Considered When Compressed Air Sys Was Originally Designed.Verified Current Design Change Process
ML17335A4281998-12-22022 December 1998
LER 98-051-00:on 981122,reactor Trip Signal from Manual Safety Injection Not Verified as Required by TS Surveillance,Was Discovered.Maintenance Currently Evaluating Significance & Cause of Event
ML17335A4111998-12-17017 December 1998
LER 98-047-00:on 981117,potential for Increase Leakage from Reactor Coolant Pump Seals Was Identified.Util Is Working with W to Resolve Issue.Current Expectations Are to Submit Update to LER by 990215.With 981217 Ltr
ML17335A4141998-12-16016 December 1998
LER 98-058-00:on 981216,postulated High Line Break Could Result in Condition Outside Design Bases for AF Occurred. Caused by Deficiencies Associated with Administration of HELB Program.Analysis of AF Will Be Completed by 990122
ML17335A4181998-12-16016 December 1998
LER 98-050-00:on 980814,ancillary Equipment Installed in Ice Condenser Was Not Designed to Withstand Design Basis Accident/Earthquake Loads.Caused by Lack of Established Design Criteria.Developed Design Criteria
ML17335A3871998-12-11011 December 1998
LER 98-031-01:on 980610,potential Common Mode Failure of RHR Pumps Were Noted.Caused by Inaccurate Values.Accurate Miniflow Numbers Have Been Determined by Flow Testing
ML17335A3821998-12-0808 December 1998
LER 98-039-01 Re EOP Step Conflicts with Small Break LOCA Analysis.Ler 98-039-00 Has Been Canceled.With 981208 Ltr
ML17335A3781998-12-0707 December 1998
LER 98-007-00:on 981106,high Energy Line Break Effects in Auxiliary FW Sys Was Noted.Cause of Event Is Under Investigation & Will Be Completed by 990220.Updated LER Will Be Submitted by 990310.With 981207 Ltr
ML17335A3771998-12-0303 December 1998
LER 98-046-00:on 981103,determined That Afs Was Unable to Meet Design Flow Requirements During Special Test.Caused by Failure to Consider All Aspects of Sys Operation in Design of Suction Basket Strainers.Sys Will Be Redesigned
ML17335A3741998-12-0202 December 1998
LER 97-011-02:on 970822,operation Was Noted Outside Design Bases for ECCS & CSP for Switchover to Recirculation Sump Suction.Caused by Ineffective Change Mgt.Revised Procedure for Switchover 01(02) Ohp 4023.ES-1.3
1999-09-17
[Table view]
Category:TEXT-SAFETY REPORT
MONTHYEARML17335A5641999-10-18018 October 1999
LER 99-024-00:on 990708,literal TS Requirements Were Not Met by Accumlator Valve Surveillance.Caused by Misjudgement Made in Conversion from Initial DC Cook TS to W Std Ts.Submitted License Amend Request.With 991018 Ltr
ML17335A5531999-10-0707 October 1999
LER 99-023-00:on 990907,inadequate TS Surveillance Testing of ESW Pump ESF Response Time Noted.Caused by Inadequate Understanding of Plant Design Basis.Surveillance Tests Will Be Revised & Implemented
ML17335A5631999-09-30030 September 1999
Monthly Operating Rept for Sept 1999 for DC Cook Nuclear Plant,Unit 1.With 991012 Ltr
ML17335A5621999-09-30030 September 1999
Monthly Operating Rept for Sept 1999 for DC Cook Nuclear Plant,Unit 2.With 991012 Ltr
ML17335A5481999-09-30030 September 1999
Non-proprietary DC Cook Nuclear Plant Units 1 & 2 Mods to Containment Sys W SE (Secl 99-076,Rev 3).
ML17335A5451999-09-28028 September 1999
Rev 1 to Containment Sump Level Design Condition & Failure Effects Analysis for Potential Draindown Scenarios.
ML17326A1291999-09-17017 September 1999
LER 99-022-00:on 990609,electrical Bus Degraded Voltage Setpoints Too Low for Safety Related Loads,Was Discovered. Caused by Lack of Understanding of Design of Plant.No Immediate Corrective Actions Necessary
ML17326A1481999-09-17017 September 1999
Independent Review of Control Rod Insertion Following Cold Leg Lbloca,Dc Cook,Units 1 & 2.
ML17326A1211999-08-31031 August 1999
Monthly Operating Rept for Aug 1999 for Cook Nuclear Plant, Unit 2.With 990915 Ltr
ML17326A1201999-08-31031 August 1999
Monthly Operating Rept for Aug 1999 for Cook Nuclear Plant, Unit 1.With 990915 Ltr
ML17326A1121999-08-27027 August 1999
LER 99-021-00:on 990728,determined That GL 96-01 Test Requirements Were Not Met in Surveillance Tests.Caused by Failure to Understand Full Extent of GL Requirements. Surveillance Procedures Will Be Revised or Developed
ML17326A1011999-08-26026 August 1999
LER 99-020-00:on 990727,EDGs Were Declared Inoperable.Caused by Inadequate Protection of Air Intake,Exhaust & Room Ventilation Structures from Tornado Missile Hazards. Implemented Compensatory Measures in Form of ACs
ML17326A0911999-08-16016 August 1999
LER 99-019-00:on 990716,noted Victoreen Containment Hrrms Not Environmentally Qualified to Withstand post-LOCA Conditions.Caused by Inadequate Design Control.Reviewing Options to Support Hrrms Operability in Modes 1-4
ML17326A0771999-08-0404 August 1999
LER 98-029-01:on 980422,noted That Fuel Handling Area Ventilation Sys Was Inoperable.Caused by Original Design Deficiency.Radiological Analysis for Spent Fuel Handling Accidents in Auxiliary Bldg Will Be Redone by 990830
ML17335A5461999-08-0202 August 1999
Rev 0 to Evaluation of Cook Recirculation Sump Level for Reduced Pump Flow Rates.
ML17326A0871999-07-31031 July 1999
Monthly Operating Rept for July 1999 for DC Cook Nuclear Plant,Unit 1.With 990812 Ltr
ML17326A0861999-07-31031 July 1999
Monthly Operating Rept for July 1999 for DC Cook Nuclear Plant,Units 2.With 990812 Ltr
ML17326A0741999-07-29029 July 1999
LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves
ML17326A0661999-07-26026 July 1999
LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr
ML17326A0651999-07-22022 July 1999
LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis
ML17326A0491999-07-13013 July 1999
LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr
ML17326A0331999-07-0101 July 1999
LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written
ML17326A0511999-06-30030 June 1999
Monthly Operating Rept for June 1999 for DC Cook Nuclear Plant,Unit 2.With 990709 Ltr
ML17326A0501999-06-30030 June 1999
Monthly Operating Rept for June 1999 for DC Cook Nuclear Plant,Unit 1.With 990709 Ltr
ML17326A0151999-06-18018 June 1999
LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified
ML17325B6421999-06-0101 June 1999
LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed
ML17325B6311999-06-0101 June 1999
LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions
ML17326A0061999-05-31031 May 1999
Monthly Operating Rept for May 1999 for Dcp.With 990609 Ltr
ML17326A0071999-05-31031 May 1999
Monthly Operating Rept for May 1999 for DC Cook Nuclear Plant,Unit 2.With 990609 Ltr
ML17325B6351999-05-28028 May 1999
LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions
ML17265A8231999-05-24024 May 1999
LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made
ML17325B6001999-05-20020 May 1999
LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed
ML17325B5861999-05-10010 May 1999
LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised
ML17325B5811999-05-0404 May 1999
LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared
ML17325B5771999-05-0303 May 1999
LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design
ML17335A5301999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for DC Cook Nuclear Plant,Unit 1.With 990508 Ltr
ML17335A5291999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for DC Cook Nuclear Plant,Unit 2.With 990508 Ltr
ML17325B5581999-04-16016 April 1999
LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold
ML17325B5471999-04-12012 April 1999
LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation
ML17325B5321999-04-0707 April 1999
LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate
ML17325B5161999-04-0101 April 1999
LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures
ML17325B5491999-03-31031 March 1999
Monthly Operating Rept for Mar 1999 for DC Cook Nuclear Plant Unit 2.With 990408 Ltr
ML17325B5441999-03-31031 March 1999
Monthly Operating Rept for Mar 1999 for DC Cook Nuclear Plant,Unit 1.With 990408 Ltr
ML17325B5221999-03-29029 March 1999
LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing
ML17325B4801999-03-18018 March 1999
LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling
ML17325B4741999-03-18018 March 1999
LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed
ML17325B5671999-03-0202 March 1999
Summary of Unit 1 Steam Generator Layup Chemistry from 980101 to 990218.
ML17325B4631999-02-28028 February 1999
Monthly Operating Rept for Feb 1999 for DC Cook Nuclear Power Station,Unit 2.With 990308 Ltr
ML17325B4621999-02-28028 February 1999
Monthly Operating Rept for Feb 1999 for DC Cook Nuclear Plant,Unit 1.With 990308 Ltr
ML17325B4571999-02-24024 February 1999
LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors
1999-09-30
[Table view] |
Text
ACCELERATED t
DISTRIBUTION DEMONSTRATION t SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
ACCESSION NBR:8809080369 DOC.DATE: 88/09/02 NOTARIZED- NO DOCKET FACIL:50-315 Donald C. Cook Nuclear Power Plant, Unit 1, Indiana & 05000315 .
AUTH. NAME AUTHOR AFFILIATION HODGE,W.M. Indiana Michigan Power Co. (formerly Indiana & Michigan Ele SMITH,W.G. Midwest Electric Cooperative RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
LER 88-006-00:on 880803,isolation of C02 fire protection R sys,w/o compensatory action due to personnel error.
W/8 ltr.
DISTRIBUTION CODE IE22D COPIES RECEIVED:LTR I ENCL TITLE: 50.73 Licensee Event Report (LER), Incident Rpt, etc.
L SIZE: D NOTES:
RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD3-1 LA 1 1 PD3-1 PD 1 1 STANG,J 1 1 D
INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DS P/NAS 1 1 AEOD/DSP/ROAB 2 2 AEOD/DSP/TPAB 1 1 ARM/DCTS/DAB 1 1 DEDRO 1 1 NRR/DEST/ADS 7E 1 0 NRR/DEST/CEB 8H 1 1 NRR/DEST/ESB 8D 1 1 NRR/DEST/ICSB 7 1 1 NRR/DEST/MEB 9H 1 1 NRR/DEST/MTB 9H 1 1 NRR/DEST/PSB 8D 1 1 NRR/DEST/RSB 8E 1 1 NRR/DEST/SGB 8D 1 1 NRR/DLPQ/HFB 10 1 1 NRR/DLPQ/QAB 10 1 1 NRR/DOEA/EAB 11 1 1 NRR/DREP/BAB 10 1 1 NRR/DREP/RPB 10 2 2 NRR/J3RISJSIB 9A 1 1 NUDOCS-ABSTRACT 1 1 G FIL~
DS'IR 02 1 1 1
RES TELFORD,J 1 1 DEPY 1 RES/DSIR/EIB 1 1 RGN3 FILE 01 1 1 EXTERNAL EG&G WILLIAMSE S 4 4 FORD BLDG HOY,A 1 1 H ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC HARRIS,J 1 1 NSIC MAYS,G 1 1 D
S
/
A TOTAL NUMBER OF COPIES REQUIRED: LTTR 46 ENCL 45
NRC Farm 'AS U.S. NUCLEAR REOULATORY COMMISSION (440)
APPROVED OMS NO. 3160410I LICENSEE EYENT REPORT (LER) EXPIRES: 4/31/44 FACILITY NAME (1) DOCKET NVI44ER (2) PA D. C. Cook Nuclear Plant - Unit I os 0 0o31 1 OF 0 4 so at>on o >re rotectlon ys em, s ou ompensatory et>on Due to Personnel Error EVENT DATE (SI LER NUMBER (4) REPORT DATE (7) OTHER FACILITIES INVOLVED (4)
SEOUENTIAL .%IS REVSION MONTH OAY YEAR FACILITYNAMES DOCKET NUMBER(s)
MONTH DAY YEAR YEAR gP NUMBER rS NUMEER 0 5 0 0 0 08 03 8 8 0 0 6 00 0 9 288 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSVANT T0 THE REDUIREMKNTs oF 10 cFR g; (checfr one or more of the forrowinol (11)
OP ERAT(NO MODE (4) 20A02(4) 20AOS(cl 50.73(el(2) (Irl 73.71 (4)
POWER 20.405(e) (1((I) 50.34(cl(1) 50.73(e l(2)(r) 73.71(cl LEYEL le)(2) 0 9 0 20 ASS( ~ I (1) (4) 50.34lc)(2) 50.73(e) (2)(rEI OTHER (Specify In Ahrtrect helow enrf In Tert, HIIC Form 20AOS(el(1)(SII 50.73(el(2) II) 50.73(el(2)(rEII(A'I 3BSAI 20AOS (e I (I) (Irl 50.73( ~ )(2)(4) 50.73(el(2)(r(4)(5) 20AOS(e I (1)(el 50.73 (IS) 50.73(e) (2)(e)
LICENSEE CONTACT FOR THIS LER l12)
NAME TELKPHONK NUMSKR W. M. Hodge AREA CODE Security Manager 616 465 -59 01 COMPLETE ONE LINK FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)
CAUSE SYS1'EM COMPONENT MANUFAG TVRER TO NPRDS ( %a .5
'AUSE SYSTEM COMPONENT MANUFAC.
TURKR EPORTASL TO NPRDS L~%
a%AWi 5 @Ievafrr'(s((LE SUPPLEMENTAL RKPORT EXPECTED (Iel MONTH OAY YEAR EXPECTED SUBMISSION OATS (15)
YES Iffyer, complete EXPECTED SUBMISSION DA FB) NO ASSTRACT ILImlt to Ic00 rpecee, EA, epproefmetery fifteen tlngreapece typewrftten float) (14)
On August 3, 1988 during isolation/normalization of the Cardox C02 Fire Protection System for the 4kv Switchgear Cable Vault, personnel error resulted in the isolation of the fir e protection system, for a period of 50 minutes, without compensatory action as required by Technical Specifi-cation 3.7.9.3, action a.
It has been concluded that in the unlikely event of a fire, personnel would have been promptly aware of its presence and been able 'to control and extinguish the fire without significant propogation or equipment damage.
To prevent recurrence appropriate administrative actions were taken con-cerning the individuals involved.
8805'080369'30902 PDR ADGCK 050003i5 S PDC NRC Form 345 (SS3)
NRC Form 366A U.S. NUCLEAR REOULATORY COMMISSION (6831 LICENSEE ENT REPORT (LER) TEXT CONTINUATION APPROVED OMS NO. 31SO&104 n
EXPIR ES: 8/31/BS FACILITY NAME (11 DOCKET NUMBER (21 LER NUMBER (61 PACE (31 D. C. Cook Nuclear Plant Unit 1 YEAR
~
g8'SOVENTIAL
.... I NVMBBR REVISION NUMBER 0 5 0 0 0 3 ] 88 0 0 6 0 0 0 2 QF 0 TECT //F'/4//ro <<>>ce /4 iso//Br/ I>>B d/Eor>>/HRC %%dnrr 3(ISA3/ (IT(
onditions Prior To ccurrence Unit 1 operating at 90 percent reactor thermal power.
Descri tion of Event On August 3, 1988, during isolation/normalization of the cardox C02 fire protection system (EIIS/KQ) for the 4kv switchgear cable vault, personnel error resulted in the isolation of the fire protection system, for a period of 50 minutes, without compensatory measures as required by Technical Specification 3.7.9.3 action a.
The sequence of events were as follows. At approximately 0745 hours0.00862 days <br />0.207 hours <br />0.00123 weeks <br />2.834725e-4 months <br /> a plant security officer was dispatched to isolate the Cardox C02 system for the 4kv switchgear room area to facilitate routine maintenance activities. [NOTE This isolation is normally accomplished by: 1) isolating the master "normal/isolation" switch (EIIS/KQ-HS) for the entire 4kv area; 2) initiating fire watch patrols at a frequency of once every 30 minutes; and 3) logging the isolation of'involved switches on the "Cardox Activity Log"]. At 0747 hours0.00865 days <br />0.208 hours <br />0.00124 weeks <br />2.842335e-4 months <br />, the security officer attempted to isolate the master switch but noted it was inoperable.
officer to isolate 4 individual switches (EIIS/KQ-,HS), three4kv This required the security switches located adjacent to the master switch outside the entrance, and one switch inside the 4kv area, at the entrance to the cable vault. Following the isolation, the security officer logged "Unit 1 4kv 4 switches", on the Cardox Switch Activity Log. While the proper switches were isolated, and compensatory fire watch coverage initiated, the security Control) officer violated Security Post Order SP0.016 (Cardox Switch in that four entries should have been logged on the tracking sheet to correspond to the four switches that were 'repositioned for the isolation of the area.
At- 0828 hours0.00958 days <br />0.23 hours <br />0.00137 weeks <br />3.15054e-4 months <br />, following completion of Maintenance activities in the area, security was requested to normalize the Cardox Systems.
Since Security post rotations had taken place a different security officer responded to the request. Upon arrival the at the 4kv switchgear room the second officer referred to Cardox switch tracking sheet to determine which switches had been isolated. The officer noted one entry ("Unit 1 4kv 4 switches"), and normalized three switches located outside the 4kv area, adjacent to the master switch. The officer failed to enter the 4kv area to normalize the switchgear cable vault cardox switch, and failed to recognize he had only normalized three switches. Fire watch coverage was discontinued at this time (0828 Hrs).
NRC FORM 3BBA *U.S.GPO:I SSS 0.624 538/455 (8831
NRC Form 366A U.S. NUCLEAR REGULATORY COMMISSION (64)3)
LICENSEE ENT REPORT (LER) TEXT CONTINUATION APPROVEO OMB NO. 3) 60M)04 EXPIRES: 8/31/88 FACILITYNAME (1) OOCKET NUMBER (2)
LER NUMBER (6) PAGE (3)
D. C. Cook Nuclear Plant Unit 1 YEAR ~ SEGUENTIAL >re'EVISION NUMBER NUMBER 3 1 5 8 8 0 0 6 0 0 0 3o" 0 4 TEXT /6'/IKBB NMBB )1 tor)U(od, IIBB aES/orN/NRC Furr 3664'4) (17)
At 0918 hours0.0106 days <br />0.255 hours <br />0.00152 weeks <br />3.49299e-4 months <br />, the same second security officer responded to an unrelated request to reisolate the 4kv area. When the officer reported the isolation to the control room, he was reminded to isolate the switch inside the 4kv area by control room personnel.
At this time the security officer discovered the deficiency and firewatch coverage was immediately reestablished. The switchgear cable vault area Cardox System had been isolated from 0828 hours0.00958 days <br />0.23 hours <br />0.00137 weeks <br />3.15054e-4 months <br /> to 0918 hours0.0106 days <br />0.255 hours <br />0.00152 weeks <br />3.49299e-4 months <br /> (50 minutes), without compensatory fire watch coverage.
Cause Of The Event This event was the result of 2 personnel errors involving the failure to properly comply with the approved procedure: 1) The security officer initially isolating the Cardox System for entry into the 4kv area failed to properly log the isolation of each individual area switch turned (Security Post Order SP0.016 requires each switch turned to be logged separately on the switch activity log, 'the security officer made one entry and noted that normalizing four switches had been turned); and, 2) the security officer the Cardox Systems referenced the switch activity log and properly read the entry as four switches, however only repositioned (normalizing) three switches. The security officer normalizing the Cardox Systems erroneously counted the switches he had repositioned.
Anal sis Of The Event The isolation of the switchgear cable vault Cardox System without compensatory fire watch coverage, was in violation of Technical Specification 3.7.9.3 action a, and is reportable under 10 CFR 50.73 (a) (2) (i) (B).
It has been concluded that in the unlikely event of a fire, personnel would have been promptly aware of its presence and been able to control and extinguish the fire without significant propagation or equipment damage. This conclusion is based on the following: 1) the relatively low fixed combustible load within of the area involved (33,552 BTU's per square foot..for a fire duration less than 30 minutes); 2) the physical and administrative limits on the introduction of transient combustibles (only a negligible amount of combustibles were present in the involved area for the duration of the event); 3) operable early warning fire detection and systems (consisting of both ionization and infrared detectors),
- 4) the existence of a trained on-shift fire brigade.
Based on the above, this event is not considered to have created any significant safety concern and did not constitute an unreviewed
'safety question as defined in 10 CFR 50.59, nor did of the it create a public.
significant hazard to the health and safety general NRC FORM 3BBA *U.S.GPO:1986.0 624 538/465 (64)3)
NRC Form 366A U.S. NUCLEAR REGULATORY COMMISSION (943)
LICENSEE ENT REPORT (LER) TEXT CONTINU ION APPROVEO OMS NO. 3150W104 EXPIRES: 8/3(/88 FACILITYNAME (I) OOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
VEAR '.v<:@'EQUENTIAL NO REVISION Unit 4$ NUMBER NUMBER D. C. Cook Nuclear Plant 1 0 5 0 0 0 3 ] 8 8 0 0 6 0 0 0 4 QF 0 4 TEXT CF/Roro EPBoo /r FBBUSBI/ Iroo a //I/ooo/NRC %%drrn 3/)//A'/ (17)
Corrective Action To prevent recurrence, appropriate administrative actions were taken concerning the individuals involved. Although the first security officer failed to follow procedural guidance in logging of the repositioned switches, the officer did provide sufficient information that the second security officer should have recognized the condition of the affected switches. The second officer simply failed to count the number of switches he repositioned/normalized.
It has been concluded that adequate procedural instruction currently exists.
In consideration of former LER 315/88-005-00 there has been individual identification numbers and isolation zone descriptions placed on each cardox control switch. These numbers may be used as an operational aid to assure the proper switch or switches are manipulated. Installation of the numbers and isolation zone information was completed on September 1, 1988.
Failed Com onent Identification Not applicable No components failed during the course of this event.
Previous Similar Events 50-315/88.-005 50-315/85-008,-020 50 316/84 009F 022F 027 50-316/83-048,-060 50-315/83-022,-028,-034,-094,-114 50-316/82-054,-058,-062,-076,-084 50 315/82 037F 044F 045F 049F 068F 081'F 082F 108 NRC FO/IM SBBA *U.S.GPO:1986 0.824 538/488 (983)
Indiana Michiga Power Cotnpany Cook Nuclear Plani P.O. Box 458 Bridgman, Ml 49106 616 465 5901 INDIANA NICHIGAN POWER September 2, 1988 United States Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555 Operating License DPR-58 Docket No. 50-315 Document Control Manager:
In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ortin S stem, the following report is being submitted:
88-006-00 Sincerely, u,~g Plant Manager WGS:clw Attachment cc: D. H. Williams, Jr.
A. B. Davis, Region M. P. Alexich III P. A. Barrett J. E. Borggren R. F. Kroeger NRC Resident Inspector J. F. Stang, NRC R. C. Callen G. Charnoff, Esq.
Dottie Sherman, ANI Library D. Hahn INPO PNSRC A. A. Blind S. J. Brewer/B. P. Lauzau
