ML18058A452

LER 92-033-00:on 920414,inoperable Control Room Penetration Occurred.Caused by Misapplication of Procedures & Inaccurate Procedures.Plant Administrative Procedure on Control of Equipment Status Will Be updated.W/920515 Ltr

ML18058A452
Person / Time
Site:	Palisades
Issue date:	05/15/1992
From:	Roberts W, Slade G CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-92-033, LER-92-33, NUDOCS 9205260141
Download: ML18058A452 (5)

Text

c*ansumers Power GB ~lade General Manager POWERINli MICHlliAN'S PROliRESS Palisades Nuclear Plant: 27780 Blue Star Memorial Highway, Covert, *Ml 49043

• May 15, 1992 Nuclear Regula~ory Commission Document Control Desk Washington, DC 20555 DOCKET 50-255 - LICENSE DPR-20* - PALISADES PLANT. -

INFORMATIONAL LICENSEE EVENT REPORT 92-033 INOPERABLE CONTROL ROOM PENETRATION DUE TO INACCURATE AND MISAPPLICATION OF PROCEDURES .

Informational Licensee Event Report (LER)92-033 is attached. This e\ ent is 1 reported in accordance with plant procedures which require that no control

• room electrical penetrations be ope_ned above cold shutdown or refueling modes of operation. * * * *

\,M/P/f~~*

Gerald B Slade *

• General Manager CC Administrator, R~gion ill, USNRC NRC Resident Inspector - Palisades Attachment

• PALISADES ll.~1/JJ' A CA.15" N7?GY COMPANV

NRC Form 388 U.s: NUCLEAR REGULATORY COMMISSION (9*83) APPROVED OMB NO. 3150-<>104 EXPIRES: B/31 /86 LICENSEE EVENT REPORT (LERI FACILITY.NAME (1) DOCKET NUMBER (2) PAGE (3)

Palisades Plant . o_ I5 I0 I0 I0 I2 I 5 I5 -1 I OF 0 I 4.

rmE <41 INFORMATIO~At LICENSEE. EVENT.REPORT 92-033 INOPERABLE CONTROL ROOM PENETRATION DUE TO INACCURATE AND MISAPPLICATION OF PROCEDURES .

EVENT DATE !61 LER NUMBER (81 REP9RT DATE (8) OTHER FACILITIES INVOLVED (Bl SEQUENTIAL ~ REVISl.ON FACILITY NAMES' MONTH DAY YEAR YEAR NUMBER NUMBER MONTH DAY YEAR N/A 0151010101 I 014 1 14 9 2 912 ol3l3 olo 615 1 I5 912 N/A 0161010101 I THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS.OF 10 CFR 1: IChttck °""or"""° of tJi. following} (111 20.4061cl

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60.38(cll1 I 60.38(c)(2)

-- 60.731*112)(i) 60. 7 31*1 (2 I (viiil!Al below and in Text,

- 60.73(o)(2)(iil 60.73(o)(2)(iii)

LICENSEE CONTACT FOR THIS LER (121

60. 7 3111121(viiil!BI 60.7:iioH2Hxl NRC Form 366AI NAME TELEPHONE NUMBER William L. Roberts, Staff Licensing Engineer COMPLETE ONE LINE FOR EACH CO.MPONENT FAILURE DESCRIBED IN THIS REPORT (131 MANUFAC* REPORTABLE

' ' J* MANUFAC- REPORTABLE CAUSE SYSTEM COMPONENT TUR ER TO NPRDS CAUSE SYSTEM COMPONENT TUR ER TO NPRDS I I I I I I L I I I I I I I

!?**.***:******:

I I I I I I I I*.*.. *:*:.:: *. I I I I I I I n

SUPPLEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR.

EXPECTED ******:******:***************

YES Vf yH, complete EXPECTED SUBMISSION DATE)

Pl NO SUBMISSION DATE 1161 I I I ABSTRACT (Umit to 1400 spaces, i.e .. approximately fifteen single-space typewritten lines) 1161 On* April 14, 1992, at approximately 0815 hours0.00943 days <br />0.226 hours <br />0.00135 weeks <br />3.101075e-4 months <br />, the plant was in hot stand-by. with the reactor critical in preparation of beginning low power physics testing. Control room floor penetration FZ-0299 was discovered to be open, with a vacuum cleaner hose and.

an electrical extension cord from the cable spreading room, running through the open penetration, to the control room. An immediate operability determination was made that the control room ventilation system remained operable with this condition. An urgent work order was initiated to cap the opening and to remove the hose and electrical cord from the penetration. The equipment was remo~ed and the penetration was capped at 0835 hours0.00966 days <br />0.232 hours <br />0.00138 weeks <br />3.177175e-4 months <br />. *

• Palisades procedures require that no openings to the control room exist when the plant is in any mode other than cold shutdown.

Therefore, when the plant exited cold shutdown with this penetration still open, the procedural limits were *exceeded.

Misapplication of the appropriate procedures and inaccurate procedures caused this event.* A lack of communications between work groups also contributed to the loss of control of this electrical penetration through the control room floor.

A lessons learned letter will-be sent to the organizations involved in this incident and the work groups whose work might involve running temporary utilities through penetrations in fire rated walls, floors and ceilings. This letter will describe that a maintenance work order is required to track the opening and closing of this kind of penetration. The plant administrative procedure on control of equipment status will be updated to assure that it is clear as to when a work order is n.eeded to control open penetrations.

,* NRC Form 388A U.S. NUCLEAR REGULATORY COMMISSION 19*831' APPROVED OMB NO *. 31~104 EXPIRES: 8/31 /86 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION FACILITY NAME 111 DOCKET NUMBER 121 LER NUMBER 131 PAGE 141 SEQUENTIAL REVISION YEAR NUMBER NUMBER Palisades Plant 0 5 0 0 0 2 5 5. 9 2 - 0. 3 3 - 0 0 0 2 OF 0 4

• EVENT DESCRIPTION On April 14, 1992, at approximately 0815 hours0.00943 days <br />0.226 hours <br />0.00135 weeks <br />3.101075e-4 months <br />, the plant was in hot standby with the reactor critical in preparation of beginning low power physics testing. Control room floor penetration FZ-0299 [Vl;PEN]was discovered to be open, with a vacuum cleaner hose and an electrical*

extension cord routed from the cable spreading room, one floor below the control roorh, through the penetration, to the control room. An immediate operability determination was made that the control room ventilation system remained operable in this condition ... An urgent work order was initiated to cap the opening and to remove the hose and electrical cord from the penetration. The equipment was .removed and the penetration was capped at 0835 hours0.00966 days <br />0.232 hours <br />0.00138 weeks <br />3.177175e-4 months <br />. System engineering was called. and asked to more formally evaluate the operability .of the control room HVAC system .

with an opening of this size. System engineering performed testing~ simulating an equivalent size opening and determined that the control room ventilation system remained operable with the penetration open, and would have continued to remain operable if the vacuum cleaner had also been operati_ng. This event is being reported in accordance with our plant administrative procedures.

The FZ-0299 penetration consists oftwo 2" condufr nipples through the control room floor, which are normally capped. In this instance, one of the two nipples had its end caps removed, and a vacuum h.ose and extension cord routed through the nipple, thus creating an open penetration.

Hisforically, it wa*s common practice during ah outage to run hoses; cords, etc., through these nipples when control room work is ongoing. This allows for vacuum cleaners and welding machines to be placed in the cable spreading room, one floor below, thereby providing less of a noise disruption to the control room while the work is in* progress. Typically a work group.

requiring the penetration to be open would notify the shift supervisor, and* the shift supervisor

• would assure that appropriate fire protection compensatory actions were taken. When the work was completed the work group would notify the shift supervisor that the penetration was closed and the compensatory action would be stopped. This is the same manner in which blocked op.en fire doors are handled under the plants Fire Protection Implementing Procedures (FPIP)-4, "Fire Protection Systems and Fire Protection Equipment."

In this instance, the penetration was opened by one work group for work in the control room, and the proper notifications were made .. The first work group completed their work but was asked by a second work group_ to leave the equipment in place for their use. When the second work group's work was completed the hose and electrical cord was left in place as it was thought that control of the opening was the responsibility of the first contractor. The first .work group assumed that the second work group would remove the hose and electrical cord, close the penetration, and make the appropriate notifications., Thus the penetration did not get closed.

~--~~*~***~~~~*~~-----_____,

.NRC Form 3661>.

(9-93)

U.S. NUCLEAR P~GULATORY COMMISSION APPROVED 0"!18 NO. 3160-0104 EXPIRES: B/31/86 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION

• FACILITY NAME 111 DOCKET NUMBER 121 LER NUMBER 131 PAGE 141 SEQUENTIAL REVISION YEAR NUMBER .NUMBER

-Palisades Plant 0 I 5 I 0 I 0 I*0 I 2 I 5 I 5 9 I2 - 0 I3 I3 . - 0 I0 0 I3 OF 0 14 Palisades procedures require that no openings to the control room exist when the plant is in any mode other than cold shutdown. Therefore, when the plant exited cold shutdown with this .

penetration still open, the procedural limits were exceeded.

Fire Protection Implementing Procedure (FPIP) 4, "Fire Protection Systems and Fire Protection Equipment," defines what .constitutes a fire barrier, versus a fire door, and provides requirements for how each is controlled. _Fire barriers are confrolled by Issuing a separate work order for each barrier that is opened. With this kind of control the bar_riers are assured to be returned to service when the associated system is returned to service, as all system work orders must be*

dispositioned prior to returning a system to service. Previously penetration FZ-0299 had been treated as a fire door in that no repair work was being performed on the barrier. Running cables or h.oses through fire doors does not require a work order. This control mechanism had been shown to work effectively o~er the years. As a result of this occurrence, FZ-0299 will now be treated as a fire barrier with its opening and closing being. controlled under a work order.

Administrative Procedure 4.02, "Control of Equipment Status," is used to determine how ec:juipment is controlled _when it is taken out of service or determined to be inoperable. At the

_ time of this event the section of Administration Procedure 4.02 describing actions to be taken for fire doors and barriers referenced the wrong section of FPIP 4, and also did not confirm that separate work orders are required for each inoperable fire barrier penetration.

CAUSE OF THE EVENT Misapplication of the appropriate procedures and inaccurate procedures caused this event. A lack

.of communications between work groups also led to the loss of control of this electrical penetration through the control room floor.

ANALYSIS OF THE EVENT At the time of the event, the plant was in hot stand-by with the reactor critical in p_reparation for beginning low power physics testing. Operations initially judged that the control room ventilation system remained operable. This was confirmed later the same day by confirmation testing completed by system engineering. To provide confirmation of operability an equivalent opening to the control room was created by opening a control room door a measured distance to simulate the floor penetrations opening. Observation of the control room internal pressure then confirmed that ventilation operability was maintained with this size of opening directly to the- control room.

System engineering also concluded that if the vacuum cleaner had also been on, enough margin still existed in the control room ventilation system to assu~e that the system would remain operable. Operability is based on maintaining-a .125" water gage positive pressure in the control room.

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NRC Form 366A U.S. NUCLEAR REGULATORY COMMISSION, (9*83i APPROVED OMB NO. 3160-0104 EXPIRES: 8/31186 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION DOCKET NUMBER 121 LER NUMBER (31 PAGE (41

. SEQUENTIAL REVISION YEAR _NUMBER NUMBER

-Palisades Plant 0 I-5 I* 0 I 0 I 0 I 2 I 5 I 5 9 I 2. - 0 I 3 I3 - 0 I0 0 I4 OF 0 I4 During the entire time that the penetration was open, fire protection compensatory measures were in place. A review of the fire tour logs shows that the penetration FZ-0299 was not entered into the fire tour log .. However, fire tours in the area of this penetration were completed during the*

entire time FZ-0299 was open. Therefore, no fire protection program limits were exceeded. As described above it was shown that the opening of this penetration had no significant adverse affect on.the ability of the control room ventilation system to perform its design basis-function ..

CORRECTIVE ACTION A lessons learned letter will be sent to the organizations involved in this incidentand the work groups whose work might involve running temporary utilities through penetrations in fire rated walls, floors and ceilings. This letter will emphasize that a maintenance work order *is required to track the opening and closing of'this kind of penetration.

• Administrative Procedure 4.02, "Control of Equipment Status," will be updated as necessary to clearly specify when a work order must be_ written to control open penetrations.

The requirements of Administrative Procedure 4.02 and the Fire Protection Implementing Procedures with regard to in_itiating work orders whenever a control room fire barrier penetration is opened, will be reviewed with the Operations Department Personnel.

ADDITIONAL INFORMATION A similar type of event was reported in LER 91-006, dated March 22, 1991.