ML17326B439

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

ML17326B439
Person / Time
Site:	Cook
Issue date:	09/02/1988
From:	Hodge W, Will Smith INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG, MIDWEST ELECTRIC COOPERATIVE
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
LER-88-006-01, LER-88-6-1, NUDOCS 8809080369
Download: ML17326B439 (6)

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