ML20205P229
| ML20205P229 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 08/25/1994 |
| From: | Wright G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Funk D NRC |
| Shared Package | |
| ML20205P063 | List: |
| References | |
| FOIA-99-76 NUDOCS 9904200084 | |
| Download: ML20205P229 (8) | |
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- UNITED STATES NUCLEAR REGULATORY COMMISSON
.f a REGION W D j 801 WARRENVILLE ROAD k j* USUE, GNOIS G0532-4351 August 25, 1994 MEMORANDUM FOR: Donald E. Funk Jr., Office Allegatica Coordinator FROM: G. C. Wright, Chief, Engineering Branch
SUBJECT:
ALLEGATION NUMBER RIII-94-n-0118, FALSIFICATION OF D. C. COOK FIRE WATCH RECORDS The Allegation Review Board met on Monday, August 22, 1994, and discussed the allegation that records of rcquired fire watches had been falsified by a contractor employee at the D. C. Cook Plant. The individual denied that the records were falsified. The employee is no longer employed at D. C. Cook.
An inspector fror. the Division of Reactor Safety (DRS) reviewed the actions taken by licensee personnel on this issue. This is documented in Section 3.3 of Inspect %n Report 315/316/94012. In addition, DRS inspectors reviewed Licensee Event Report 94-005-00 (attached) and the descriptions of the problem and the actions taken which were included in Condition Report 94-0969 (sttached). Licensee actions appeared to be adequate and no further actions are considered necessary. Allegation Number RIII-94-A-Oll8 should be closed.
/d !
- G C. Wright, f )
Engineering Branch
]
Attachments:
- 1. Licensee Event Report 94-005-00
- 2. Condition Report 94-0969 ,
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June 9, 1994 United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-58 -
Docket No. 50-315 Document control Manager:
In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Report System. the following report is being submitted:
94-005-00 Sincerely, b*
A. A. Blind Plant Manager
/sb Attachment c: J. B. Martin, Region III E. E. Fitzpatrick P. A. Barrett R. F. Kroeger M. A. Bailey - Ft. Hayne NRC Resident Inspector "
J. B~. Hickman - NRC .
J. R. Padgett G. Charnoff, Esq.
D..Hahn INPO
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eAca,rry Manas M loocart5.aeFAca eAat m D. C. Cook Nuclear Plant - Unit 1 l 05000 315 1 OF 3 T'n2 m Failure of Fire Watch Personnel to Perform Assigned Duties Resulting in Missed TS Required Surveillance EVENT DATE (5) LER NUMOER (61 REPORT NUMBER (7) OTHER FACIUTIES INVOLVED (8) i uoHTH Day vtAA vtM *** uoNTw OAv vtAA
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12 28 93 94 0005 00 06 09 94 05000 OPEHATING THfS REPORT IS SUBMITTED PURSUANT TO LtE REQUIREMENTS OF 10 CFR k (Check one or more) (11)
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UCENSEE CONTACT FOR THIS L1 ', "2) naa t rummx wuwe % c W. M. Hodge - Plant Protection Superintendent 616-465-5901 COMPLETE ONE UNE FOP f ACH COMPONENT FAILURE DESCRIDED IN THtS REPORT (13) came systru couroen ua-ur crunca l
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SUPPLEMENTAL REPORT EXPCCTED (14) $ EXPECTED ""' D l 'IA8 '
vts p yes. =pme EXPECrID SUGMr$ son D*M " l SUBMISSION X l OATE (15) .
l ABS $ACT (Umrt to 1400 spaces. i e. approximately 15 single-spaced typewritten lines) (16) on 6/1/92, the fire protection for multiple areas of the Plant was declared inoperable due to the uncertainties regardi.ng the fire proofing material used to protect components and cabling within those areas. Compensatory actions required by the Technical Specifications (TS) were established. On 2/11/94, a routine review of completed Fire Watch ( W) patrol records identified three (3) discrepancies in which an hourly FW patrol on the Essential Service Water (ESW) pump room was not conducted for a period of 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> 29 minutes"on 12/28/93,1 bour 38 minutes on 12/30/93 and 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> 29 minutes on 12/31/93.
Additional reviews were conducted and identified one (1) additional discrepancy in which an hourly W patrol ws9 not conducted on the U-1 CD Emergency Diesel Generator (EDG) room for 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> 22 minutes on 2/24/94.
A random monitoring program has been developed to review W tours. These events, lessons learned from these evence, and management expectations were conveyed to Plant Protection personnel. W patrol training and implementing procedures are being revised to incorporate the lessons learned from these events.
anc ma us .vetca asouwo.v co-=.oa E p***I5- 4/3042 UCENSEE EVENT REPORT (LERI TEXT CONTINUATION SE.'
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010 012 OF voer n- . - - : , e ,,,,,, ,mm an 0 13 DESCRIPTION OF EVENT On 6/1/92, the fire protection for multiple areas of the Plant was sieclared inoperable due to the uncertainties regarding the fire proofing material used to protect components and cabling within those areas. ,
On 2/11/94, a routine review of completed FW patrol tour records associated .
with TS related Fire Doors (FD) and other non-safety related FD for the months of November and December 1993, and January 1994, was conducted. This review revealed five discrepancies attributed to a single FW individual at the Unit 1 ESW pump room (door designation 1-GT-SCN212A-323).
From this review, the FW tour records generated by this individual for the time period November 17 through December 31, 1993 were exmn!ned to determine the extent of the problem. Twenty-two (22) total discrepancies w2re identified for this individual. Of the 22 discrepancies, three (3) were determined to have exceeded the regt.irements of TS 3.7.10. The other nireteen (19) were determined to have violated procedural requirements. No compensatory actions were taken as this review was of past events.
Based on these two reviews, a review was conducted of an additional 10% of the TS related FW patrols / tours and other non-safety related FW and FD tours for the period December 1993 through February 1994. This review identified si.x (6) additional procedural violations and one (1) discrepancy that had exceeded the requirements of TS 3.7.10. The discrepancy involved the U-1 CD EDG room.
CAUSE OF EVENT For the documentation reviewed, it appears the cause was the failure of the individual (s) to perform their assigned duties. A contributing cause to these events was that management follow-up/ monitoring of activitiJs did not identify the discrepancies.
ANALYSIS OF EVENT The TS 3.7.10 action statement for an inoperable fire rated assembly requires that *...withim 1 hours1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> 1) verify that the fire detectors and/or fire suppression system on at least one side of the inoperable assembly are OPERABLE and establish an hourly fire watch patrol, or 2) establish a continuous fire watch patrol on one side of the penetration. . .".
Failure to maintain an hourly W patrol was a violatien of TS 3.7.10 and is reportable un(.or 10 CFR 50.73(a)(2)(1)(B).
The U ". ESW pump room (Fire Zone 29-G) and U-1 CD EDC room (Fire Zone 15) was being toured because it contains fire protective coating material which the Plant declared inoperable on 6/1/92. The hourly FW patrol was not conducted
~ for' a period of 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> 29 minutes on- 12/28/93, I hour 38 minutes on 12/30/93 and l' hour 29 mi.nutes on 12/31/93 in the ESW pump roca. The hourly FW patrol was not conducted for a penriod of I hour 22 minutes on 2/24/94 in the U-1 CD ane r, aan.
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.u-UCENSEE EVENT REPORT (LER) E'T.o'.f"E"E,"nSEsT' c noE Ea"m'a"a2 TEXT CONTINUATION E "as"EnE's E =T s"a E 'I E U U U L* Va;o*:& G .C.' M 23'"a*:. M : 3 .9 0, asassatseestatt asuc eupGET,maswa= Gross,0C 3eeaa.
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D. C. Cook Nuclear Plant - Unit 1 o l5 l 0 l 0 l 0 l 3 l 1 l5' 9l 4 -
0l0l5 -l0l0 0l3 or 0l3 TaxT as- . -- _: ,.iew assawstn ANAI.YSIS OF EVENT feont*di EDG room. The analysis of this event concludes that in the unlikely event of a fire, personnel would have been promptly aware of its presence and would have extinguished the fire without significant spreading of the fire or .
equipment damage. This conclusion is based on the following:
- 1. The detection for F'Z 29-G and FZ-15 was in En operable state, in the event of a fire, the detectors would have alarmed in the U-1 Control Room, which is manned 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> a day. This alann condition wou.',d have been investigated and the appropriate Fire Brigade resources would have been dispatched to mitigate the fire.
- 2. Manual fire protection equipment was readily available for Fire Brigade use if they deemed necessary.
Although an hourly W patrol was not conducted for 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> 29 minutes, I hour 38 minutes, 1 bour 29 minutes and.1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> 22 minutes respectively, it is concluded that the alarms / detection associated with the affected FZ would have allowed timely identification of a fire. Therefore, these events are not considered to have created a significant safety concern, nor did it create a significant hazard to the health and safety of the general public.
CORRECTIVE ACTION
- 1. A random monitoring program was developed to review fire watch tours.
- 2. These events, lessons learned and management expectations were conveyed to Plant Protection personnel during meetings held during the month of May 1994.
- 3. Fire Watch patrol training and implementing procedures are being revisec' to incorporate the lessons learned from these events.
PREVIOUS SIMILAR EVENTS None mac e anna es .
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Page 7 of l
Condition Report 94-0969 Investigation During.a routine review of tour. records, ten percent of Technical Specification Fire Doors, Appendix A Fire Doors and Fire Watch (FM) tour records were reviewedThe for review the months of' November consisted and December of a comparison of.
1993, and January 1994; the completed logs against the security computer door. transaction records. (The review was restricted to flocations Lequipped with cardreaders.) The review found five discrepancies attributed to-and five discrepancies attributed to2a four singlesecurity officersFour of the security officer discrepancies were FW person. There attributed to a misunderstanding of the room to.be' toured. The. officers.
was no intentional f alsification of tour records.The fif th discrepancy was 'f;tributed simply toured the wrong area.to a security officer touring the required area ten minut to the required start time. The five remaining discrepancies were at tributed to the FW at the Unit 1. Essential Service Water pump room (FDB door designation 1-GT-SCN212A-323) and could not be mitigated.
As a follcw up to the initial record review, FW tour records generated by the FW responsible for the five1993 discrepancies noted were examined to above for November 17 through December 31, Twenty-three total determine the extent of the which problem.
discrepancies Ofwere identified are attributed to this individual. the 23 discrepancies three were determined to be occurred. on which Technical Specification 3.7.10 violations 12/28/93 (one violation 0030 - 0130)', 12/30/93 (one violation 0030
- 0130) and 12/31/94 (one violation 0030 - 0130).
Computer transaction records indicate that the FW was aware of theTh location of the tour points.
been missed were visited by the FW during tour rounds completed FW training was prior to or on the dates of the discrepancies. the FW accurately completed. During an investigative interview,
' described the requirements for conducting a FW tour. . There were no conflicting assignments which would have prevented visiting The FWall of also the required tour points during the interview, thatscheduled rounds.all required tour points were stated during theThe FW to which these events are attributed is no longer checked.
at Cook Plant.
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Pcge 71 of Condition Report 94-0969 Investigation During a routine review of tour records, ten percent of Technical Specification Fire Doors, Appendix A Fire Doors and Fire Watch (FW) tour records were reviewedThe for the months review of November consisted and December of a comparison of 1993, and January 1994e the completed logs against the security computer door transaction records. (The review was restricted to locations equipped with cardreaders.) The review and found five discrepancica attributed to five discrepancies attributed to a four security officers single FW person. Four of the security officer discrepancies There were attributed to a misunderstanding of the room to be toured. The officers was no intentional falsification The of fif tour th records. was. attributed discrepancy simply toured the wrong area.
to a security officer touring The the required area ten minutes prior five remaining discrepancies were to the required start time.
attributed to the FW at the Unit 1 Essential Service Waternot and could pump be room (FDB door designation 1-GT-SCN212A-323) ,
mitigated. 4 As a follcw up to the initial record review, FW tour records generated by the FW responsible for the five1993 discrepancies were examinednoted to l above for November 17 through December 31, Twenty-three total determine the extent of the which problem.
were identified are attributed to this discrepanciesof individual. the 23 discrepancies three were determined to be which occurred on Technical Specification 3.7.10 violations 12/28/93 (one violation 0030 - 0130), 12/30/93 (one violation 0030
- 0130) and 12/31/94 (one violation 0030 - 0130).
Computer transaction records indicate that the FW was aware of the location of the tour points. The tour points identified as having been missed were visited by the FW during tour rounds completed FW training was prior to or on the dates of the discrepancies. the FW accurately completed. During an investigative interview, described the requirements for conducting a FW tour. There were no conflicting assignments which would have prevented visiting all of the required tour points during the scheduled rounds. The FW also stated during the interview, that all required tour points were checked. The FW to which these events are attributed is no longer at Cook Plant.
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5 Page N 'of --
Condition Report 94-0969 Two of the violations initially documented on the Condition R.eport-were resolved because personnel trained as FW had entered the area within the required time frame based upon Technical Specification bases 3/4.0 paragraph 4.0.2 which allows a maximum extension The not to-areas exceed 25% of the specified surveillance interval.
resolved in this way are the Unit 1 Essential Service FeedWater.
on 12/30/93 Pump Room-(ESW FDB door designation 1-GT-SCN212A-323) One between 0630 and 0730 and on 12/31/93 between 0430 and 0530.
additional violation attributed to the FW was- identif%d during this investigation. That violation was the ESW pup room on 12/31/93 form 0030 to 0130. This additional violation is reference in the-text above.
Based upon the results of the initial review an additional ten percent of Technical Specification Doors, Appendix A Doors and FWand January and~
tour records for the months of December 1993, February 1994 wsre reviewed (increasing the original 10% to 20% for The results of the months of December, 1993 and January, 1994).
A of this the second review are contained in Attachment investigation. The expanded review identified an additional Technical Specification 3.7.10 violation which occurred on 2/23/94 for the Unit 1 CD Diesel Generator Room between 2230 and 2330.
No additional This FW is no longer working at Cook Plant. j investigation is warranted, i' No additional investigation is warranted in that, the reviews conducted have identified the programmatic cencerns and adequate Further, the corrective / preventative actions were identified.
items identified verse the sample size reviewed are not considered ineffactive per Mi.litary standard 105d.
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~ Page i of _
Condition Report 94-0969 Backussed PMI 2270 Fire Protection implements the requirement for FW tours to compensate for:
- inoperable fire barriers or fire barrier sealing devices
- inoperable fire doors
- inoperable Tech Spec related fire doors
- inoperable fire dampers
- non-functional cable tray or conduit fire protective material
- non-functional gap seals The organization controlling the FW contractor is responsible for training contractor personnel in requirements of PMI 2270 or ensuring that the contractor has implemented a training program.
12 SHP 2270 FIRE.011 " Fire Watch Activities", provides for control and qualification of FW activities and establishes controls. for Technical Specificatien compensatory measures and welding, burning, grinding Fire Watches.
contractor The 12 SHP FIRE.01:. is implemented by an onsite The SMP provides specifically hired to provide onsite FW services guidance on FW requirements.
The SHP assigns responsibility to the contractor to:
- a. Perform training in accordance with attachments 6 and 7 of the procedure.
- b. Assure all contractor Fire Watches are properly trained in their duties in conformance with an approved training program.
- c. Maintain documented evidence of the training.
- d. Ensure the prompt and timely posting of all required Fire Watches.
e, Ensure only qualified Teca Spec Fire Watches are posted.
- f. Assure posted Fire Watches properly discharge duties.
g'. Conduct at least one surveillance per shift to assure Fire' Watches discharge duties.
O Pege /b of Condition Report 94-0989
- h. coordinate multiple /2 ~,.ned.
Watches in an area te assure proper coverage to mau
- 1. Fill out F$re Watch log fo. each posting.
- j. Review all completed Firt t *ch logs.
k Review and approve all Fire Watch logs.
Watch logs to plant Fire
- 1. Transmic completed Fire Protection Coordinator.
- m. Resolve questions or problems reported by Fire Watch personnel.
for proper operation of Fire Watch
- n. Be responsible systems.
Management direction for monitoring of centractor FW activities is initiated by SAso .01e Fire Watch Activitv Verificattgn. The SASC requires a quarterly random check of FW activities to verify that FW tours and posts are being conducted as required. The SASO allows the random checks to be accomplished by a review of security door transaction records or in-plant observations to verify the FW had arrived at the required area within the specified time.
concerns The investigation identified several areas of concern with the management of the FW tour activities, as follows:
- 1. 12 SHP 2270 FIRE.011 is unclear asThere training program.
to whatareconstitutes no an stated approved FW responsibilities for review and approval of training progra was no periodic materials. At the time of this event the: 1 IEM monitoring of the training provided by te contractor te FW personnel.
The FW qualification process appears to be weak. There was ne 2.
required supervisory monitoring of the On-The-Job Training to ensure training was adequate for it's intended purpose.
- 3. At the time of this event, interviews indicate shift tour surveillances were being conducted by contract supervision.
However, licensee oversight was not conducted, i
9.. b
. G Page d of Condition Report 94-0969 the:. quarterly
- 4. The instruction (SAso.018) implementing
-monitoring of FW tours does not state requirements for sample size'or acceptance criteria to ensure the FW tours are being properly implemented.
- 5. The current practice of . generating tour log data sheets .by transcription and hand- increases the opportunity for legibility errors.
- 6. The method of identifying inoperable seals is ~ inadequate.
Presently, the seal number is written foot Normal' on masking traffic or duct and tape cleaning and placed on the floor.
activities degrade the tape and number over time.
- 7. No guidance / standards exist There asistonothe purpose stated for reviewing purpose for the and approving review of FW FW logs. tour logs or the criteria used for approving logs.
- 8. FW supervisor responsibilities relative. to' ~FW systems It is unclear as to-the intent2270 operation are not stated. currently of-this responsibility as stated in 12 SHP FIRE.011.
- 9. The investigation identified situations where FW personnel did not have appropriate security cardreader access to areas to be toured.
10 The team believes there have been cases where FW personnel were confused over the difference between the Technical There also~
Support Center (TSC) and the TSC computer Room.
between the.UPS Battery Room appears to have been confusionand the UPS Battery Inverter Room ba computer transaction logs.
- 11. There was an accepted practice of signing off an area toured
~by another EW or Security _ officer.
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Page I of Condition Report 94-0969 Root Cause Baced upon the existing evidence noted during this investigation and the concerns identified, the primary root cause for the three-Technical Specification 3.7.10 violations is.A50.01, a failure secondary cause of isa Fire Watch to perform the required task.
13.20 Management follow-up or monitoring of activities did not identify problems. No security computer problems were identified to be which would have caused the door transaction records incomplete.
identified'which No hardware or maintenance activities could be would have caused the security computer door transaction records to be incomplete.
Corrective Actions Taken
- 1. FP 004 Tour Administrative
/ Surveillance was Guideline developedtotoMonitor establish Fire Protection a ten percent random monitoring program for FW tours.
- 2. The Security Cardreader access status for all Fire Watches has been changed to allow entry into all areas on the FW tours.
- 3. The FW contractor has issued a memo to all FW personnel directing them to contact security immediately if the security cardreader will not grant entry into a location to be toured.
- 4. Meetings were held during May 1994 with FW and Security personnel to outline expectations and the significance of falsification of tour activities.
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, A *) c. }oh-e Page l$ ot.
Condition Report 94-0969-Preventive Actions The following actions address the concerns identified during this investigation and if implemented.should prevent _ recurrence.
- 1. Delineate in an appropriate procedure, the responsibilities of I & M personnel for the review and approval'of the FW training.
program, to include lesson plan content, format'and the FW qualification process.
- 2. Develop and. implement a formalized OJT process (for each of-the responsibilities of a FW) to address specific plant layout and terminology. Included in this process should for FWbeduties, a clear understanding of management expectations layout, and standardized minimum plant- knowledge, plant terminology which is to be demonstrated by all potential Fire Watches.
- 3. Develop and implement a method of generating the tour log sheets to ensure clarity and consistency of the entries.
44 Evaluate the adequacy of the method currently used to identify inoperable seals.
- 5. Revise the department procedure which controls FW activities to1
- Define what is meant by the review / approval of FW logs.
- Define the parameters the supervisor must verify to indicate proper performance of the tour.
- Reference the FW tour log in the procedure text.
- Require a printed name and initials on tour log sheets.
State the specific FW supervisor. responsibilities relative to FW systems operation.
- Define how tour points are to be added and subtracted 1 during a shift.
- Revise the tour sheet to include: )
- Tour-Point and location
- Reason for tour-(inoperable Gap Seal ......)
- Requirement for. proper tour L enter area, check for
. smoke. and fire,- ensure entry / exit cardreader transactions are obtained)
-4