ML19354E162
| ML19354E162 | |
| Person / Time | |
|---|---|
| Site: | Braidwood  |
| Issue date: | 12/18/1989 |
| From: | Kinsella J, Querio R COMMONWEALTH EDISON CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| BW-90-0028, LER-87-006-03, NUDOCS 9001290040 | |
| Download: ML19354E162 (8) | |
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E u ' , 4~ Commonwe:lth Edison f-c-jf Braldwood Nucltir Powcr Stition
. . Routa C1, Box B4 Braceville. Illinois 60407 i ' Telephone 815/458-2801.
January 10,1990 BW/90-0028 l
l U. S. Nuclear Regulatory Commission !
Document Control Desk Washington, D.C. 20555 Dent Sir:
The enclosed Licensee Event Report from Braidwood Generating Station is being transmitted to you as a Supplemental Report to LER 87-006-00.-
This report is number 87-006-01; Docket No. 50-456.
L' Very truly yours, i
(l/ s
- C9 a' vd a R. E. Querlo Station Manager Braidwood Nuclear Station REQ /JDW/jfe l (7126z)
Enclosure:
Licensee Event Report No. 87-006-01 cc: NRC Region III Administrator l< NRC Resident Inspector INPO Record Center CECO Distribution List
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Missed hourly and continuous Fire watches due to miscommunications, c 1. p o. g y .. 1425 inattentiveness, and cognitive personnel gA;g gg error of contractor personnel.
MA55 FC$t MPlJPGNIAL RDCEI This Supplemental Report is being issued to document additional occurrences in 1987. .
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title (4) Missed Hourly and Continuous Fire Watches Due to Miscosununications, Insttentioness, and Cognitive Personnel Error of Contractor Personnel.
.iV20tJate (5) LER Naster (6) Report Date (7) Otht r. Facilities IDichtf_lf)
Sequential Revision Month Day Year Facility Names _ _ Docket Numberft)
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of 1 21 o el 7 BI 7 oIe16 oI 1 1i2 11_2 81 9 ofslofof01.1 I THl$ REPORT 15 $UBMITTED PUR$UANT TO THE REQUIREMENi$ OF 10CFR 5 LChtd_one er mere of the f olinwino) (111
" 50.73(4)(2)(tv) 73.7)(b) 20.402(b) __ 20.405(c) _ _
POWE R _ 20.405(a)(1)(4) _ 50.36(c)(1) _ 50.73(a)(2)(v) _ 73.71(c)
LEVEL 20.405(a)(1)(11) 50.36(c)(2) 50.73(a)(2)(vii) .__ Other ($pecify 0l0!O (101 _ ?0.405(a)(1)(iii) 1 50.73(a)(2)ti) 50.73(a)(2)(viii)(A) in Abstract 20.405(a)(1)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) below and in
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LICENSEE CONTACT FOR THis LEP (12)
TELEPHONE N@EER Name J. Kinsella, Fire Marshal Est. 2764 , p g; ,, ,, g g g CQt!P1[TE ONE LINE FOR EACH COMPON NT FAILURE DESCRIBED IN THIS REPORT (13)
COMPONEH1 MANUFAC. REPORTABLE' CAU$E $YSTEM COMPONENT MANUFAC- REPORTABLE
- CAUSE $YSTEM TURER TO NPRDS TURER TO NPRDS I I I I I I I I I I I I I I l l i 1 I l ~l I I I I _J l l SUPPLEENTAL RE*0RT EXPECTED (14) Espected Month l Day l Year Submission lye s (I f .yt L__tgatlfit_[LP[(T(D _ SUBw15510N._.DAT E ) l NO Da u ( W g ],lg AB51RAC1 (Lielt to 1400 spaces, i.e approximately fif teen single-space type =ritten lines) (16)
' These are the additional events associated with inattentive fire watches in 1987: At 0400 on March 28, 1967 the route 4 hourly fire watch patrol was detained by radiation chemistry personnel due to not signing the latest radiation work permit. The fire watch was unaware of the requirement to notify radiation chemistry of the time r;quirements associated with fire watch duties. At 0600 on March 31. 1987 the route 4 hourly fire watch patrol was waiting to be relieved at the starting point of the route, and did not start the route at 0605. The cause of this event was a cognitive personnel error in that the fire watch f ailed to restart the route while awaiting watch relief. At 1355 on May 10, 1967 and at 0555, on May 14 1987 are two cases of fire watch inattentiveness.
These events were caused by cognitive personrel errors due to inattentiveness to duty. The corrective act4 ens were as follows: f or the March 28 and March 31, 1967 occurrences the fire watch personnel were retrained regarding actions required by the fire watch. For the May 10 and May 14 1987 occurrences the fire watch personnel were terminated. Previous occurrences of fire watch inattentiveness are documented in 1 50 456/86-001-01.
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A .' PLANT CONDIT!DN5 PRIOR TO EVENT: ,
0;CURRENCE DATE M00t RK POWER RCS(AB)TEMr/FRES 01/20/87 5 - C0t0 S W1t0 W 0% 168 OtG f/385 PSIG 02/07/87- 5 - COLD $W1DOW 01 106 DEG F/370 PSIG 8 lDCSCR1pTION OF EVENT:
January 20, 1987 occurrence: All fire rated assemblies have been declared inoperable, since receipt of the fuel 7 .1 cad license, because of ongoing construction. Due to this condition an hourly fire watch patrol has been
" ' established in all saf ety-related fire areas and areas containing redundant systems important to safe shutdown.
- Fire detectors have been verified operable on at least one side of the inoperable assemblies.
On January 20, 1967 at approntmately 1425 the route #6 hourly fire watch patrolman exited the 346' elevation in
-the auxiliary butiding, and entered a stairway to proceed down to the 330' elevation on which the Unit i essential' service weter ($X) (t!) pump room is located. As the patrolman entered the stairway, she observed red caution flags streng down the stairwey end signs stating, " wet paint." The patrolman attempted several times to contact the fire watch supervisor, but was unsticcessful. The patrolman was confused and not sure of what actions to take. Due to habit, the patrolman entered her signature in the fire watch log, indicating that she had patrolled
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the unit 1 SK' pump rote at 1425. Fearing that she would not reach her next log-in location on time, the patrolmew -
cintinued the patrol without having entered the unit 1 SX pump room. .
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At approximately 1525, the patrolman reached the same stairway leading to the unit 1 $s pump room 'and encountered . <
the same condition. The patrolman did not try to contact the fire watch supervisor because she planned to tell Me about the problem at the 1600 post check. Once again, the patrolman entered her signature in the fire watch.
' Irg, indicating that she performed the hourly fire watch in the unit 1 SK pump room at 1525. The patrolman
' ctntinued the patrol without' having entered the unit 1 $X pump room.
At approximately 1600, the patrolman met the fire watch supervisor at the end of route #6 for a post check. The patrolman has stated that at this point, she informed the fire watch supervisor that because of the painted I stairway she could not patrol the unit 1 $X pump room at 1425 or 1525. The fire watch supervisor did not reply cr ctnfirm that he acknowledged the message. The fire watch supervisor has stated that he did not hear the L patrolman mention that an hourly patrol had not been perf ormed. The supervisor has also explained that since the log was filled out correctly f or all entries prior to the post check, he had no reason to believe that an hourly patrol had not been performed at 1425 or 1525.
!' Af ter the post check was completed, another fire watch patrolman relieved the route #6 patrolman and assumed the h urly fire watch daties.
At cpproximately 1625, the new patrolman arrived at the f reshly painted stairwell and isonediately contacted the fire watch supervisor. The supervisor lastructed the patroiman to continue patrolling the route and he would
-chech the stairway. A suming that the supervisor would chec6 the unit I su puM roce. the patrolman signed thi log for that location at 1625 and continued the patrol without having entered the unit 1 su pump room.
Shortly thereafter, the supervisor arrived at the Heir.a3 and else ot'strsed det apM ared to tt a freshi) re m tet' stairway prohibiting entry to the '30' elevation. The supervisor innediately proceeded to the shif t engineer's office, l'
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- 9. DESCRIPTION Of EVENT: (Con't)
Inf ormed of the situation, the shif t engineer contacted on assistant fire marshal. The assistant fire marshal
. informed him that the patrolman should proceed down the f reshly painted steps in a safe manner so that the patrol cculd be completed on time. This information was conveyed to the route #6 patrolman. The fire watch supervisor failed to patrol the 300' elevation at 1625 and he also failed to infore the shift engineer of this fact.
At' appresimately 1715, the station fire protection engineer and the assistant fire marshal inspected the stairway in question end deterwined that only one half of the stairway had been painted. also, the painting crew had strung l rid caution flags down the center of the stairs, thus maling provisions for the fire watch patrolman to proceed down the dry side.
i At approrimately 1725, the route #6 patrolman entered the unit 1 sa pump room and patrolled the area. All subsequent hourly fire watch patrols in this area were performed satisfactorily.
On January 21, 1987, an assistant fire marshal was reviewing the fire watch logs for January 20, 1967 and l discovered a handwritten note at the bettee of the route #6 log. The note was written after the 1700 hourly patrol of the 330' elevation, and states that the Unit 1 SX pump roos was not patrolled at 1625 due to wet point l I
$n the stairs.
personnel from the fire protection office inmediately investigated the incident. After reviewing the computer acesss logs for the times in question and speaking with security personnel involved with the incident, it was deterwined that an hovely fire watch was not performed in the unit i SX pump room at 1425, 1525 or 1625 on January 20, 1987.
February 7, 19B7 occurrence:
Th> CO2 (KQ) Fire Suppression systems f or mones 15-43 and 15-44, which are located in lower cable spreading rooms 121 cnd 122, have been inoperable since 10-17-86. Due to this condition, a continuous fire watch (post (3) has
-bi:n implemented in accordance with Technical Specification 3.7.10.3.
At 0642 on February 7,1987, two electrical maintenance forseen were perforwing their biweekly hoosekeeping inspection of the lower cable spreading rooms and observed an inattentive continuous fire watch (post #3).
Several minutes later, the foreman walked past the fire watch and he did not acknowledge their presence or seee capable of performing fire watch duties. At that moment an individual approached and spoke to the fire watch.
The fire watch became attentive and resumed his fire watch duties. The foreman prepared a written report of their observations, which they presented te the fire marshal.
These are additional fire watch occurrences relative to construction activities which occurred prior to January
- 1. 1988.
At 0400 on March ?8,1987 the route 4 hourly fire watch patrol was detained by Radiation Cheelstry personnel. The watch, who did not sign the latest Radiation Work Fervit, could not enter the Auxiliary Building. The watch imediately signed the applicable perrit, but was twenty four rinutes late before patrolling the 420' elevation in the Auxiliary Building. Failure to patrol the area within one hour of the last patrol performed violated T echni cal Speci f ic a t ion 3.7.11, Fire Ra ted As serrblies .
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- 9. Ot$CRIPi!0N OF EVENT: (Con't)
At 0600 on March 31, 1987 the route 4 hourly fire watch patrol was waiting to be relieved at the starting point of the route. Contrary to procedure requireseets, the patrol did not start the route at 0605. Due to a lack of personnel evallability, the scheduled relief was approsimately 30 minutes late. As a result, the general areas of the 426' and the 451' elevations on the auxiliary building were patrolled approximately 50 and 22 minutes late, respectively. Failure to patrol these areas within one hour of the last patrol performed violated technical specification 3.7.11, fire Rated Assemblies.
'At 1355 on May 10. 1987 Burns Security reported that the roving fire watches found the U-1 lower cable spreading room lights out. At 1400, a shif t supervisor investigated and found the Newburg fire watch sleeping. The shift supervisor immediately notified the shif t engineer who notified the Newburg fire watch supervisor. The Newburg supervisor then reported to the lower cable spreading roce at which time the fire watch awakened. The fire watch was turned over to the fire watch supervisor.
l At 0555, on May 14, 1987 the Project Construction Department Superintendent found the continuous fire watch for
! the Diesel Auxiliary Feedwater Pump Room (nattentive. The fire watch was ismediately reprimanded and was then i
permanently relieved free the post at 0615. The fire watches inattentiveness ef fectively violated the Technical Specification Action Statement requi. ring a ' continuous
1 These occurrences are being reported under the requirements of 10CFR50.73(a)(2)(1)(b) which states that the
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IIcsnsee shall report any operation or condition which is prohibited by the plants technical specifications.
C. CAUSE Of EVENT:
l January 20, 1987 occurrence:
Rrot Cause:
- 1. Cognitive personnel error by both fire watch patrolmen and the fire watch supervisor (all are contractor personnel) since they f ailed to realize that only half of the stairway was freshly painted and a path was lef t a11 ewing thee to patrol the unit 1 $X pump room.
Intermediate Causes:
- 1. Fersonnel Error
- a. The fire watch patrolmar. fror 1400 until 1600 did not comply with approved orders by failing to innediately notify the fire watch supersiser or shif t engineer that conditions prevented her f roer completing the patrol.
l L. Neither fire watch patrolman performed in accordance with written procedures. The patrolmen entered their initials in the fire watch log for the unit 1 $X pump room at 1425. 1525 and 1625, indicating that the reor had been patrolled. However, the patrolman f or the 1625 round placed a note in the fire watch leg explaining the circumstances under which she placed her initials in the fire watch log.
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TERT Energy Industry Identification Systes (E!!$) codes are identified in the tent as (um) I l
@.-CAU$ eof-EYJNT: -(Con't)
- 2. ..Cormunicetions Error
- a. . The fire watch patrolman f rom 1400 untti 1600 f ailed to confire, during the post check, that the fire watch supervisor understood that two hourly fire watches were not pet formed,
- b. The fire watch supervisor f ailed to.comununicete to the shif t engineer that a fire watch had not been performed at 1625.
February.-7, 1987 occurrence: Inattentive fire watch (contractor personnel). )
March'28, 1987 occurrence: The fire watch was unaware of the requirement to notify radiation chemistry of the time requirements associated with fire watch duties.
l March 31, 1987 occurrence: The cause of this event was a cognitive personnel error in that the fire watch failed to restart the route while awaiting watch relief.
ThE May 10 and the May 14, 1987 events were caused by cognitive personnel errors due to inattentiveness to duty. q D. SAFETY ,ANALY$l$: .
January 20,' 1987 occurrence: There was no effect on plant safety as the permanently installed fire detection instrumentation in the writ 1 SX pump room was operable at the time.
The fire hazards analysis states that this fire zone contains one $X pump and strainer f roe each unit. Redundant pumps and strainers are located in an adjacent fire zone. These two tones are separated by a flood proof fire
.wall. Either zone will provide full operational capability for. both units.
Fcbruary 7, 1987 occurrence: there was no effect on plant safety as the permanently installed fire detection instrumentation was functional at the time. Also, room 1:2 is covered by another continuous fire watch, post 84.
! E. CORRECTIVE ACTIONS:
January 20, 1987 occurrence:
I' j 1. The two fire watch patrolmen and the fire watch supervisor have been instructed by the security contractor 1- supervision about> the importance of being attentive to plant conditions while performing fire watch patrols.
L It was also explained to ther that the plant foremen conf er with the fire marshal, prior to painting any area, so that paths are left for the fire watch patrols.
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- t. CORRCCTIVE ACTIONS: (Con't) e
- 2. The fire watch patrolman, who patrolled f ree 1400 until 1600, has been instructed to isumediately contact the fire watch supervisor or shif t engineer whenever the satisfactory completion of a fire watch is in jeopardy.
This wl11 ensure that adequate actions can be taken or support can be obtained.
- 3. Both fire watch patro1 men have been retrained on the requirements of bwsp 1100-13, fire watch inspectiers, and the proper method of documentation in the fire watch log, 4 The fire watch petrolman, who patrolled f rom 1400 until 1600, and the fire watch supervisor have been instructed about improving coasnunications while on fire watch duty. Any problems or potential problems shall be tsunediately brought. to the attention of the proper supervisory personnel, and it should be confirmed that the message has been acknowledped.
- 5. Based on the actions taken by the 1400 to 1600 patrolman, it has been decided by the licer see, that this person should be denied access to the Braidwood Station. This decision has been relayed to the security contractor, burns security, in a letter, dated February 16, 1987.
Isbruary 7, 1987 cccurrence:
- 1. The fire watch's employment was terminated after the end of his shift due to his inattentiveness.
- 2. Training sessions presented to all continuous fire watch personnel continue to stress the importance of being attentive while performing fire watch duties.
- 3. Fire watch supervisors and meenbers of the fire marshal's staf f continue to make unannounced rounds of the ,
fire watch posts to assure that the fire watch personnel are alert.
For the March 28 and March 31, 1987 occurrences the fire watch persormel were retrained regarding actions required by the fire wat:h.
For the May 10 and May 14, 1987 occurrences the fire watch personnel were terminated.
F. PREVIOU$ OCCURRENCES:
DVR/LER NU'OER TITLE 20-1-86-009/86-001 Violated fire Watches Due to personnel Errors G. COMPONENT FAILURE DATA: None.
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