05000311/LER-1997-016-01, :on 970909,loss of Fire Protection Water to Auxiliary Bldgs & Containment Was Noted.Caused by Human Error Due to Inattention to Detail.Loss Prevention Tours Have Been Revised to Include Once Per Shift Verification

:on 970909,loss of Fire Protection Water to Auxiliary Bldgs & Containment Was Noted.Caused by Human Error Due to Inattention to Detail.Loss Prevention Tours Have Been Revised to Include Once Per Shift Verification

ML18106A187
Person / Time
Site:	Salem
Issue date:	11/14/1997
From:	Enrique Villar Public Service Enterprise Group
To:
Shared Package
ML18106A186	List: 05000311/LER-1997-016, Forwards LER 97-016-00 Re Loss of Fire Protection Water to Auxiliary Bldgs & Containments.Ler Was Originally Submitted on 971015 as LER 97-003-00.Encl Is Being Resubmitted W/Next Sequential LER Number 05000311/LER-1997-016-01, :on 970909,loss of Fire Protection Water to Auxiliary Bldgs & Containment Was Noted.Caused by Human Error Due to Inattention to Detail.Loss Prevention Tours Have Been Revised to Include Once Per Shift Verification
References
LER-97-016-01, LER-97-16-1, NUDOCS 9712090139
Download: ML18106A187 (5)

LER-1997-016, on 970909,loss of Fire Protection Water to Auxiliary Bldgs & Containment Was Noted.Caused by Human Error Due to Inattention to Detail.Loss Prevention Tours Have Been Revised to Include Once Per Shift Verification

Event date:
Report date:
3111997016R01 - NRC Website

text

• ....

NRCFORM366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 (4-95)

EXPIRES 04/30/98 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS MANDATORY INFORMATION COLLECTION REQUEST: 50.0 HRS.

Ll9ENS~E EVENT REPORT (LER)

REPORTED LESSONS LEARNED ARE INCORPORATED INTO THE LICENSING PROCESS AND FED BACK TO INDUSTRY.

FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (T~ F33J U.S. NUCLEAR (See reverse for required number of REGULATORY COMMISSIOJ!n WASHINGTON, DC 20 !;s:Ooo1i': AND TO THE PAPERWORK REDU ON PROJECT ~3150-0104), 0 FICE OF digits/characters for each block)

MANAGEMENT AND BUDGET, WASHINGTON, C 20503.

FACILITY NAME (1)

DOCKET NUMBER (2)

PAGE(3)

SALEM GENERATING STATION UNIT 2 05000311 1 OF 5 TITl.E (4)

LOSS OF FIRE PROTECTION WATER TO THE SALEM UNIT 1 AND 2 AUXILIARY BUILDINGS AND CONTAINMENTS.

EVENT DATE (5)

LER NUMBER (6)

REPORT DATE (7)

OTHER FACILITIES INVOLVED (8)

FACILITY NAME DOCKET NUMBER MONTH DAY YEAR SEQUENTIAL MONTH DAY YEAR YEAR I NUMBER I REVISION NUMBER STATION UNIT 1 05000272 09 09 97 97 016 00 11 14 97 FACILITY NAME DOCKET NUMBER 05000 OPERATING THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check one or more) (11)

MODE(9) 20.2201(b) 20.2203(a)(2)(v)

50. 73(a)(2)(1)

50. 73(a)(2)(vlll)

POWER 20.2203(a)(1) 20.2203(a)(3)(1)

50. 73(a)(2)(11)

50. 73(a)(2)(x)

LEVEL(10) 20.2203(a)(2)(1) 20.2203(a)(3)(11)

50. 73(a)(2)(111) 73.71 20.2203(a)(2)(11) 20.2203(a)(4)

50. 73(a)(2)(1v) x OTHER 20.2203(a)(2)(111) 50.36(c)(1)

50. 73(a)(2)(v)

Spec~ln Abstract below or In C Form 366A 20.2203(a)(2)(1v) 50.36(c)(2)

50. 73(a)(2)(vll)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER (Include A,.* Code)

E. H. Villar (Station Licensing Englnner) 6093395456 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE

SYSTEM COMPONENT MANUFACTURER REPORTABLE

CAUSE

SYSTEM COMPONENT MANUFACTURER REPORTABLE TONPRDS TONPRDS SUPPLEMENTAL REPORT EXPECTED (14)

EXPECTED MONTH DAY YEAR IYES x1NO SUBMISSION (If yes, complete EXPECTED SUBMISSION DATE).

DATE(15)

ABSTRACT (Umlt to 1400 spaces, I.e., approximately 15 single-spaced typewritten lines) (16)

At 2210 hrs on September 16, 1997, a Unit 1 Nuclear Control Operator (NCO) identified that the fire protection water for Salem Units 1 and 2 Auxiliary Buildings and Containment was isolated.

Fire protection water for these areas is supplied via valves 1FP186 and 1FP187, which were found closed.

While the exact cause of the valves being mispositoned could not be determined, the valves were most probably misaligned during relamping activities on September 9, 1997. The cause of the condition going unidentified is attributed to human error due to inattention to detail by the NCO and the Loss Prevention Operators during subsequent panel reviews.

Fire protection personnel were promptly notified, and the valves were opened at 2237 hrs.

Pursuant to License Conditions 2.C.(10) and 2.I of the Unit 2 Facility Operating License, a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> report and a follow-up Special Report were made to the NRC on September 17 and September 30, 1997, respectively.

This Special Report is being Specification Section Report.

97120 90139 971114 ADOCK 05000311 PDR PDR s

6

• 9

• 3 I made* in accordance with Technical and supplements the September 30 Special

J (4-95)

FACILITY NAME (1)

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION U.S. NUCLEAR REGULATORY COMMISSION DOCKET NUMBER (2)

LER NUMBER (6)

PAGE (3)

SALEM GENERATING STATION UNIT 2 05000311 YEAR I SE,fill,feT,tL I ~

2 OF 5

97 -

016 00 TEXT (If more space Is required, use additional copies of NRC Fonn 366A) (17)

PLANT IDENTIFICATION:

Salem Generating Station - Unit 2 Public Service Electric and.Gas Company Hancocks Bridge, New Jersey 08038 IDENTIFICATION OF OCCQRRENCE:

Loss of Fire Protection Water to Salem Units 1 and 2 Auxiliary Buildings and Containments.

Date of Occurrence:

Date of Identification Report Date:

September 9, 1997 September 16, 1997 November 14, 1997 CQNDITIONS PRIOR TO OCCQRRENCE:

Salem Unit 1 - Defueled Salem Unit 2 -

Mode 1 approximately 58% Power DESCRIPTION OF OCCQRRENCE:

The following is a timeline of the events, as recreated from operators logs, interviews, and a brief summary of the event recreation, as well as a level one root cause investigation Time line July 15, 1997 - Valves 1FP186 and 1FP187 were stroked open and closed using surveillance procedure SC.FP-ST.FS-0007.

September 1, 1997-Valves 1FP186 and 1FP187 were locally position verified open by Loss Prevention personnel.

September 2, 1997 -

1FP147 was stroked open and closed during performance of procedure Sl.RA-IS.ZZ-0001, "Types B And C Leak Rate Test."

The controls for 1FP147 are located on panel 1RP5, immediately to the right of the control for 1FP186 and 1FP187. (4-95)

U.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITY NAME (1)

DOCKET NUMBER (2) 05000311 SALEM GENERATING STATION UNIT 2 TEXT (If more space Is required, use addltlonail copies Of NRC Form 366A) (17)

DESCRIPTION OF OCCURRENCE (cont'd):

LER NUMBER 6)

YEAR I SEQUENTIAL NUMBER REVISION NUMBER 97 -

016 00 PAGE(3) 3 OF 5

September 6, 1997 -

I&C Craft personnel started relamping activities at panel lRPS per Work Order.

September 9, 1997 -

I&C Craft personnel completed relamping lRPS. Work Order notations and personnel interviews indicate that valves 1FP186 and 1FP187 were relamped on the second night the panel was worked on. This work was performed from 2100 hrs on September 8 to 0700 hrs on September 9, 1997.

September 16, 1997 - At 2210 hrs a Unit 1 NCO noted that the indicator for valves 1FP186 and 1FP187 was illuminated, and at 2225, the valves were field verified closed by Loss Prevention personnel.

At 2237, Operations personnel opened the valves, and at 2243, the valves were field verified open by Loss Prevention personnel.

Pursuant to License Conditions 2.C. (10) and 2.I of the Unit 2 Facility Operating License, a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> report and a follow-up Special Report were made to the NRC on September 17 and September 30, 1997, respectively.

This Special Report is being made in accordance with Technical Specification Section 6.9.3, and supplements the September 30, Special Report.

CAUSE OF OCCURRENCE:

The exact cause of how the 1FP186 and 1FP187 valves were closed, and could have potentially been closed from September 1, 1997, through September 16, 1997, could not be determined.

These dates represent the times when the 1FP186 and 1FP187 valves were field verified open by Loss Prevention personnel.

However from the timeline of the events, as presented above, the most probable cause for the inadvertent closure of the 1FP186 and 1FP187 valves was relamping activities on lRPS panel on September 9, 1997. (4-95)

U.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITY NAME (1)

DOCKET NUMBER (2) 05000311 SALEM GENERATING STATION UNIT 2 TEXT (If more space la required, use additional copies of NRC Fonn 366A) (17)

CAUSE OF OCCURRENCE (cont'd):

LER NUMBER 6)

YEAR I SEQUENTIAL NUMBER 97 -

016 00 PAGE(3) 4 OF 5

The cause for this condition going unidentified for the period from September 9, 1997, through September 16, 1997 is attributed to human error due to inattention to detail by the Nuclear Control Operators and the Loss

- Prevention Operators during subsequent panel reviews.

The reviews did not focus on valve position indication, but were focused on verification of alarm status and lamp functionality.

PRIOR SIMILAR OCCURRENCES:

A search of the LER database using the phrase "fire protection" did not identify any LERs within the past five years related to mispositioned fire protection valves.

Similar searches were performed using the same phrases as described above for the corrective action program database searches, and no applicable documents were identified.

SAFETY CONSEQUENCES AND IMPLICATIONS

Although fire suppression was potentially unavailable during the period from September 1 (when the valves were field verified opened) to September 16 (when the valves were again field verified opened), there were hourly roving fire watch tours of the Unit 1 and 2 Auxiliary Buildings.

These roving fire watch tours were established for other unrelated fire protection issues, but they did provide a level of assurance that a fire would not have gone undetected.

PSE&G has an onsite dedicated Fire Protection Department.

Additionally, the fire protection detection system for the Auxiliary Buildings and Containments was unaffected by the closure of the 1FP186 and 1FP187 valves, which provides the primary means of detection.

CORRECTIVE ACTIONS TAKEN:

The valves were opened at 2237 hrs on September 16, 1997, and locally verified open by Loss Prevention personnel at 2243 hrs.

• LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION.

FACILITY NAME (1)

SALEM GENERATING STATION UNIT 2 U.S. NUCLEAR REGULATORY COMMISSION DOCKET NUMBER (2)

LER NUMBER (6)

PAGE (3) 05000311 YEAR I 8F;fil'=AL I== 5 OF 5

97 -

016 00 TEXT (If more apace rs required, use addltlonal copies of NRC Fonn 366A) (17)

CORRECTIVE ACTIONS TAICEN (cont'd):

On September 18, 1997, Loss Prevention personnel completed a lineup verification of Fire Protection valves (C02 and Water) at Salem station, and as a temporary compensatory measure, initiated position verification of the 1FP186 and 1FP187 valves on a twice per shift (every 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />) basis pending completion of the cause investigation.

The monthly verification of Hope Creek valves was performed the week prior so no further action was initiated for Hope Creek.

Loss Prevention tours have been revised to include a once per shift verification of valve position for 1FP186 and 1FP187.

This measure will remain in place until the lRPS panel status report checklist is revised to include verification of 1FP186 and 1FP187 indicator lamp test once per shift.

Operators will receive training on the controls associated with the 1FP186 and 1FP187 valves. This training will be completed by November 30, 1997.

An event notice will be issued to Operations, Work Control, Loss Prevention and Station Planning to share the lessons learned from this event.

This notice will be issued by October 31, 1997.