ML17326B439

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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 American Electric Power icon.png
Issue date: 09/02/1988
From: HODGE W M, SMITH W G
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

ttACCELERATEDDISTRIBUTIONDEMONSTRATIONSYSTEMREGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ACCESSIONNBR:8809080369DOC.DATE:88/09/02NOTARIZED-NODOCKETFACIL:50-315DonaldC.CookNuclearPowerPlant,Unit1,Indiana&05000315.AUTH.NAMEAUTHORAFFILIATIONHODGE,W.M.IndianaMichiganPowerCo.(formerlyIndiana&MichiganEleSMITH,W.G.MidwestElectricCooperativeRECIP.NAMERECIPIENTAFFILIATION

SUBJECT:

LER88-006-00:on880803,isolationofC02fireprotectionsys,w/ocompensatoryactionduetopersonnelerror.W/8ltr.DISTRIBUTIONCODEIE22DCOPIESRECEIVED:LTRIENCLLSIZE:TITLE:50.73LicenseeEventReport(LER),IncidentRpt,etc.NOTES:RDRECIPIENTIDCODE/NAMEPD3-1LASTANG,JINTERNAL:ACRSMICHELSONACRSWYLIEAEOD/DSP/NASAEOD/DSP/TPABDEDRONRR/DEST/CEB8HNRR/DEST/ICSB7NRR/DEST/MTB9HNRR/DEST/RSB8ENRR/DLPQ/HFB10NRR/DOEA/EAB11NRR/DREP/RPB10NUDOCS-ABSTRACTRESTELFORD,JRES/DSIR/EIBEXTERNALEG&GWILLIAMSESHSTLOBBYWARDNRCPDRNSICMAYS,GCOPIESRECIPIENTLTTRENCLIDCODE/NAME11PD3-1PD11111111111111111111111122111111ACRSMOELLERAEOD/DOAAEOD/DSP/ROABARM/DCTS/DABNRR/DEST/ADS7ENRR/DEST/ESB8DNRR/DEST/MEB9HNRR/DEST/PSB8DNRR/DEST/SGB8DNRR/DLPQ/QAB10NRR/DREP/BAB10NRR/J3RISJSIB9AGFIL~02DS'IRDEPYRGN3FILE0144FORDBLDGHOY,A11LPDR11NSICHARRIS,J11COPIESLTTRENCL11221122111011111111111111111111111111DDS/ATOTALNUMBEROFCOPIESREQUIRED:LTTR46ENCL45 NRCFarm'AS(440)LICENSEEEYENTREPORT(LER)U.S.NUCLEARREOULATORYCOMMISSIONAPPROVEDOMSNO.3160410IEXPIRES:4/31/44FACILITYNAME(1)D.C.CookNuclearPlant-UnitIDOCKETNVI44ER(2)os00o31PA1OF04soat>ono>rerotectlonysem,souompensatoryet>onDuetoPersonnelErrorEVENTDATE(SILERNUMBER(4)REPORTDATE(7)OTHERFACILITIESINVOLVED(4)MONTHDAYYEARYEARgPSEOUENTIAL.%ISREVSIONNUMBERrSNUMEERMONTHOAYYEARFACILITYNAMESDOCKETNUMBER(s)05000080388006000928805000OPERAT(NOMODE(4)POWERLEYEL09020A02(4)20.405(e)(1((I)20ASS(~I(1)(4)20AOS(el(1)(SII20AOS(eI(I)(Irl20AOS(eI(1)(el20AOS(cl50.34(cl(1)50.34lc)(2)50.73(el(2)II)50.73(~)(2)(4)50.73le)(2)(IS)LICENSEECONTACTFORTHISLERl12)50.73(el(2)(Irl50.73(el(2)(r)50.73(e)(2)(rEI50.73(el(2)(rEII(A'I50.73(el(2)(r(4)(5)50.73(e)(2)(e)0THEREDUIREMKNTsoF10cFRg;(checfroneormoreoftheforrowinol(11)THISREPORTISSUBMITTEDPURSVANTT73.71(4)73.71(clOTHER(SpecifyInAhrtrecthelowenrfInTert,HIICForm3BSAINAMEW.M.HodgeSecurityManagerTELKPHONKNUMSKRAREACODE616465-5901COMPLETEONELINKFOREACHCOMPONENTFAILUREDESCRIBEDINTHISREPORT(13)CAUSESYS1'EMCOMPONENTMANUFAGTVRERTONPRDS(%a.5'AUSESYSTEMCOMPONENTMANUFAC.TURKREPORTASLTONPRDSL~%a%AWi5@Ievafrr'(s((LESUPPLEMENTALRKPORTEXPECTED(IelYESIffyer,completeEXPECTEDSUBMISSIONDAFB)NOASSTRACTILImlttoIc00rpecee,EA,epproefmeteryfifteentlngreapecetypewrfttenfloat)(14)EXPECTEDSUBMISSIONOATS(15)MONTHOAYYEAROnAugust3,1988duringisolation/normalizationoftheCardoxC02FireProtectionSystemforthe4kvSwitchgearCableVault,personnelerrorresultedintheisolationofthefireprotectionsystem,foraperiodof50minutes,withoutcompensatoryactionasrequiredbyTechnicalSpecifi-cation3.7.9.3,actiona.Ithasbeenconcludedthatintheunlikelyeventofafire,personnelwouldhavebeenpromptlyawareofitspresenceandbeenable'tocontrolandextinguishthefirewithoutsignificantpropogationorequipmentdamage.Topreventrecurrenceappropriateadministrativeactionsweretakencon-cerningtheindividualsinvolved.8805'080369'30902PDRADGCK050003i5SPDCNRCForm345(SS3)

NRCForm366A(6831LICENSEEENTREPORT(LER)TEXTCONTINUATIONnU.S.NUCLEARREOULATORYCOMMISSIONAPPROVEDOMSNO.31SO&104EXPIRES:8/31/BSFACILITYNAME(11D.C.CookNuclearPlant-Unit1DOCKETNUMBER(21LERNUMBER(61YEARg8'SOVENTIAL~....INVMBBRREVISIONNUMBERPACE(31TECT//F'/4//ro<<>>ce/4iso//Br/I>>Bd/Eor>>/HRC%%dnrr3(ISA3/(IT(050003]88-0060002QF0onditionsPriorToccurrenceUnit1operatingat90percentreactorthermalpower.DescritionofEventOnAugust3,1988,duringisolation/normalizationofthecardoxC02fireprotectionsystem(EIIS/KQ)forthe4kvswitchgearcablevault,personnelerrorresultedintheisolationofthefireprotectionsystem,foraperiodof50minutes,withoutcompensatorymeasuresasrequiredbyTechnicalSpecification3.7.9.3actiona.Thesequenceofeventswereasfollows.Atapproximately0745hoursaplantsecurityofficerwasdispatchedtoisolatetheCardoxC02systemforthe4kvswitchgearroomareatofacilitateroutinemaintenanceactivities.[NOTE-Thisisolationisnormallyaccomplishedby:1)isolatingthemaster"normal/isolation"switch(EIIS/KQ-HS)fortheentire4kvarea;2)initiatingfirewatchpatrolsatafrequencyofonceevery30minutes;and3)loggingtheisolationof'involvedswitchesonthe"CardoxActivityLog"].At0747hours,thesecurityofficerattemptedtoisolatethemasterswitchbutnoteditwasinoperable.Thisrequiredthesecurityofficertoisolate4individualswitches(EIIS/KQ-,HS),threeswitcheslocatedadjacenttothemasterswitchoutsidethe4kventrance,andoneswitchinsidethe4kvarea,attheentrancetothecablevault.Followingtheisolation,thesecurityofficerlogged"Unit14kv-4switches",ontheCardoxSwitchActivityLog.Whiletheproperswitcheswereisolated,andcompensatoryfirewatchcoverageinitiated,thesecurityofficerviolatedSecurityPostOrderSP0.016(CardoxSwitchControl)inthatfourentriesshouldhavebeenloggedonthetrackingsheettocorrespondtothefourswitchesthatwere'repositionedfortheisolationofthearea.At-0828hours,followingcompletionofMaintenanceactivitiesinthearea,securitywasrequestedtonormalizetheCardoxSystems.SinceSecuritypostrotationshadtakenplaceadifferentsecurityofficerrespondedtotherequest.Uponarrivalatthe4kvswitchgearroomthesecondofficerreferredtotheCardoxswitchtrackingsheettodeterminewhichswitcheshadbeenisolated.Theofficernotedoneentry("Unit14kv-4switches"),andnormalizedthreeswitcheslocatedoutsidethe4kvarea,adjacenttothemasterswitch.Theofficerfailedtoenterthe4kvareatonormalizetheswitchgearcablevaultcardoxswitch,andfailedtorecognizehehadonlynormalizedthreeswitches.Firewatchcoveragewasdiscontinuedatthistime(0828Hrs).NRCFORM3BBA(8831*U.S.GPO:ISSS0.624538/455 NRCForm366A(64)3)LICENSEEENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONAPPROVEOOMBNO.3)60M)04EXPIRES:8/31/88FACILITYNAME(1)D.C.CookNuclearPlant-Unit1TEXT/6'/IKBBNMBB)1tor)U(od,IIBBaES/orN/NRCFurr3664'4)(17)OOCKETNUMBER(2)YEAR31588LERNUMBER(6)~SEGUENTIALNUMBER006>re'EVISIONNUMBER-00PAGE(3)03o"04At0918hours,thesamesecondsecurityofficerrespondedtoanunrelatedrequesttoreisolatethe4kvarea.Whentheofficerreportedtheisolationtothecontrolroom,hewasremindedtoisolatetheswitchinsidethe4kvareabycontrolroompersonnel.Atthistimethesecurityofficerdiscoveredthedeficiencyandfirewatchcoveragewasimmediatelyreestablished.TheswitchgearcablevaultareaCardoxSystemhadbeenisolatedfrom0828hoursto0918hours(50minutes),withoutcompensatoryfirewatchcoverage.CauseOfTheEventThiseventwastheresultof2personnelerrorsinvolvingthefailuretoproperlycomplywiththeapprovedprocedure:1)ThesecurityofficerinitiallyisolatingtheCardoxSystemforentryintothe4kvareafailedtoproperlylogtheisolationofeachindividualareaswitchturned(SecurityPostOrderSP0.016requireseachswitchturnedtobeloggedseparatelyontheswitchactivitylog,'thesecurityofficermadeoneentryandnotedthatfourswitcheshadbeenturned);and,2)thesecurityofficernormalizingtheCardoxSystemsreferencedtheswitchactivitylogandproperlyreadtheentryasfourswitches,howeveronlyrepositioned(normalizing)threeswitches.ThesecurityofficernormalizingtheCardoxSystemserroneouslycountedtheswitcheshehadrepositioned.AnalsisOfTheEventTheisolationoftheswitchgearcablevaultCardoxSystemwithoutcompensatoryfirewatchcoverage,wasinviolationofTechnicalSpecification3.7.9.3actiona,andisreportableunder10CFR50.73(a)(2)(i)(B).Ithasbeenconcludedthatintheunlikelyeventofafire,personnelwouldhavebeenpromptlyawareofitspresenceandbeenabletocontrolandextinguishthefirewithoutsignificantpropagationorequipmentdamage.Thisconclusionisbasedonthefollowing:1)therelativelylowfixedcombustibleloadwithintheareainvolved(33,552BTU'spersquarefoot..forafiredurationoflessthan30minutes);2)thephysicalandadministrativelimitsontheintroductionoftransientcombustibles(onlyanegligibleamountofcombustibleswerepresentintheinvolvedareaforthedurationoftheevent);3)operableearlywarningfiredetectionsystems(consistingofbothionizationandinfrareddetectors),and4)theexistenceofatrainedon-shiftfirebrigade.Basedontheabove,thiseventisnotconsideredtohavecreatedanysignificantsafetyconcernanddidnotconstituteanunreviewed'safetyquestionasdefinedin10CFR50.59,nordiditcreateasignificanthazardtothehealthandsafetyofthegeneralpublic.NRCFORM3BBA(64)3)*U.S.GPO:1986.0624538/465 NRCForm366A(943)LICENSEEENTREPORT(LER)TEXTCONTINUIONU.S.NUCLEARREGULATORYCOMMISSIONAPPROVEOOMSNO.3150W104EXPIRES:8/3(/88FACILITYNAME(I)D.C.CookNuclearPlant-Unit1OOCKETNUMBER(2)LERNUMBER(6)VEAR'.v<:@'EQUENTIAL4$NUMBERNOREVISIONNUMBERPAGE(3)TEXTCF/RoroEPBoo/rFBBUSBI/Irooa//I/ooo/NRC%%drrn3/)//A'/(17)050003]880060004QF04CorrectiveActionTopreventrecurrence,appropriateadministrativeactionsweretakenconcerningtheindividualsinvolved.Althoughthefirstsecurityofficerfailedtofollowproceduralguidanceinloggingoftherepositionedswitches,theofficerdidprovidesufficientinformationthatthesecondsecurityofficershouldhaverecognizedtheconditionoftheaffectedswitches.Thesecondofficersimplyfailedtocountthenumberofswitchesherepositioned/normalized.Ithasbeenconcludedthatadequateproceduralinstructioncurrentlyexists.InconsiderationofformerLER315/88-005-00therehasbeenindividualidentificationnumbersandisolationzonedescriptionsplacedoneachcardoxcontrolswitch.Thesenumbersmaybeusedasanoperationalaidtoassuretheproperswitchorswitchesaremanipulated.InstallationofthenumbersandisolationzoneinformationwascompletedonSeptember1,1988.FailedComonentIdentificationNotapplicable-Nocomponentsfailedduringthecourseofthisevent.PreviousSimilarEvents50-315/88.-00550-315/85-008,-02050316/84009F022F02750-316/83-048,-06050-315/83-022,-028,-034,-094,-11450-316/82-054,-058,-062,-076,-08450315/82037F044F045F049F068F081'F082F108NRCFO/IMSBBA(983)*U.S.GPO:19860.824538/488 IndianaMichigaPowerCotnpanyCookNuclearPlaniP.O.Box458Bridgman,Ml491066164655901INDIANANICHIGANPOWERSeptember2,1988UnitedStatesNuclearRegulatoryCommissionDocumentControlDeskWashington,D.C.20555OperatingLicenseDPR-58DocketNo.50-315DocumentControlManager:Inaccordancewiththecriteriaestablishedby10CFR50.73entitledLicenseeEventReortinSstem,thefollowingreportisbeingsubmitted:88-006-00Sincerely,u,~gPlantManagerWGS:clwAttachmentcc:D.H.Williams,Jr.A.B.Davis,RegionIIIM.P.AlexichP.A.BarrettJ.E.BorggrenR.F.KroegerNRCResidentInspectorJ.F.Stang,NRCR.C.CallenG.Charnoff,Esq.DottieSherman,ANILibraryD.HahnINPOPNSRCA.A.BlindS.J.Brewer/B.P.Lauzau