_ _ _ _ _ _ _ _ _ . . _ _ _ _ ,__

e

LICENSEE EVENT REPORT (LER) I orm Rev. 2.0

Factdry Name (1) Docket Number (2) Page (3)

Quad Cities Unit One 0|5|0|0|0|2|5|4 1 | of | 0 | 5Inic (4)

Continuous Firewatch Not Established Following Impairment Of A safe shutdown Path.Event Date (3) LER Number (6) Report Date (7) Other Facihues Involved (5),

Morin Day Year icar sequennal Revision Month Day Year f acthry Docket humberts)Number Number Names

i 015|0|0|01 | |

0|1 2|1 9|4 9|4 - 0|0|3 - 0j0 0|2 1|8 9|4 0|S|0|0|0| | |OPERATING Till5 REPORT 15 SUBM11 iLD PUX5UANT i O Tile R NUIREMENTS OF 10CI R

MODE (9) (Check one or more of the following) ill)j4 2u.402(b) 20.405(c) 50.73(a)(2niv) 73.71(b)

POWER 20.405(aX1Xi) 50.36(cXI) 50.73(a)(2Xv) ~~~73.71(c)

LEVEL 20.405(a)(IXii) 30.36(cX2) 50.73(ax2 Xvii) Other (Specify

(10) |9| 7 20 405(aXIXiii) T50.73(ax2xi) 50.73(aX2)(viiiXA) m Abstract'20.405(aXIXiv) 50.73(aK2)(ii) 50.73(aK2XvtiiXB) below and in

20.405(a)(IXv) 50.73(aK2Xiii) 50.73(aX2Xx) Text)

LICENSEE CON 1 ACT FOR Tills LER (12)

NAME TELEPIIONE NUMBERAREA CODE

Dale McCullough Ext. 3120 3 0|9 6|5|4|-|2|2|4|1COMPLETE ONE LINE I OR EACll COMPONENT FAILURE DESCRIBED IN - IIIS lj!OORI (13)

SYSl LM COMPONENT MANUFACTURER REPORTABLECAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE(|CAU5b TO NPRDSTD NPRDS

E | | | | | | | | | | | | | |

| | | I I l I I I I I ISUPPLEMENTAL REPOR1 flPLCTED 04) Expected Month Day Year

Submission

YES (If yes. complete EXPECTED SUBMISSION DATE) y'O Date (15) | | |ABSlRACT (Limit to 1400 spaces, i.e.. approxunately fif teen smgle-space typewrmen Ames)(16)

1. ABSTRACT:

Unit one was in the RUN mode at approximately 97% of rated core thermal power on 1/21/94.Unit Two was shutdown with the Reactor (Rx) Mode switch in the REFUEL position. The UnitTwo Emergency Diesel Generator (EDG) [KL] was Out of Service (005) which placed the Unit ina Limiting Condition for Operation (LCO). requiring hourly compensatory firewatch measures(which were in place). At 1600 on 1/21/94 it was noted that the Unit 1/2 Rx Recirculation |System Motor Generator Set Deluge " Water Curtain" system [KP] had also been 005 during thetime period (from 1/15/94 to 1/21/94) the EDG was 005 (12/29/94 to 1/21/94), Per OCAP1500-2 " Administrative Requirements For Inoperable Safe Shutdown (SSD) Equipment", the ,simultaneous 00Ss of a SSD equipment system and a Fire Protection (FP) system in the same !

"

(SSD) path required that a continuous, rather than an hourly firewatch, be established.

The primary Causal Factors for this event were inadequate verbal communications andtraining which resulted in shift supervision misinterpreting procedural requirements.Contributing causal factors were written communications, and change management. Writtencommunications and training have previously been identified as elements of programmaticproblems with the appendix R safe shutdown program. Corrective actions to address thesecausal factors are planned and in the process of being implemented.

Proper compensatory measures were established. Designated Operations personnel willreceive additional training on the Fire Protection Administrative Requirements /SSDprocedpres in retraining sessions during the first quarter of 1994.

LER254M3M 9403110254 940218PDR ADOCK 0500o254R PDR

- _ . - - . - . . . . - . . . - . _ _ -

. ,_ . . - . _ - - _ . . , .

EADILITY NAME(s}

. LICENSEE EVENT REPORT (LER) TEXT CONTINU ATION Form Rev. 2.0

DOC 11T NUMBER (2) LER NUMBER (6) PAGE (3). Year Sequenual Reusmn

% Number Number

Quad Cities Unit One 0|5|0|0|0|2|5|4 9|4 - 0|0|3 - 0|0 2 |OF| 0 | 5TEXI. Energy industry Idenuficanon System (EUSJ codes are idenufted m the text as (XX)

PLANT AND SYSTEM IDENTIFICATION:

General Electric - Boiling Water Reactor - 2511 MWt rated core thermal power.

EVENT IDENTIFICATION: Continuous firewatch not established following impairment of a safeshutdown path.

A. CONDITIONS PRIOR TO EVENT:

Unit: One Event Date: January 21. 1994 Event Time: 1600Reactor Mode: 04 Mode Name: Run Power Level: 97

This report was initiated by Licensee Report 254\94-003.fRUN-(4) - In this position the reactor system pressure is at or above 825 psig and

the reactor protection system is energized, with APRM protection and RBM interlocksin service (excluding the 15% high flux scram).

B. DESCRIPTION OF EVENT _t

ON 12/29/93 Unit one was in the RUN mode at approximately 97% of rated'

core thermal power. Unit Two was shutdown with the Reactor (Rx) Mode'

switch in the REFUEL position. The Unit two Emergency Diesel Generator(EDG), which is classified as a piece of Safe Shutdown (SSD) equipment,was taken Out Of Service (OOS) for maintenance. Per QCAP 1500-2, '" Administrative Requirements For Inoperable Safe Shutdown Equipment"procedure, this placed the Unit in a seven (7) day Limiting Conditionfor Operation (LCO), requiring hourly compensatory firewatch measures.The compensatory firewatches were properly established and performed.

On 1/15/94 the Unit 1/2 Rx Recirculation system Motor Generator (MG)set Deluge " Water Curtain" system [KP] (which is a Fire Protection (FP)system) was taken OOS for maintenance. A review of the OOS by shiftsupervision did not identify the need to establish a continuous firewatch as required by QCAP 1500-2.

At 1154 on 1/21/94 the EDG was returned to service and the continuousfirewatch was no. longer required. At 1600 on 1/21/94, the ShiftEngineer noted there had been an OOS of FP equipment on a SSD pathaffected by the OOS on the Unit 2 EDG during the same time period. -PerQCAP 1500-2,- the simultaneous OOSs on a SSD equipment system and a FPsystem which impacts a SSD path affected by the SSD OOS, requires thata continuous, rather than an hourly firewatch, be established. AProblem Identification Form (PIF) was writtta to document theoccurrence evaluate its' cause. !,

a

LER254i94\003.WPF

_ - . _ . _ _ . - _ _ .

-~- . - _. - . . - . - .

2 foremen

UCENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rev. 2.0

FACLUTY N AME (1) DOCKET NUMBER (2) LLR NUMBER (6) PAGEQ)Year Sequennal Revision*

Number Number

0|0|3 - 0|0 3 |OF| 0 | 5Quad Cities Unit One 0|5|0|0|0|2|5|4 9|4 -TLXT Energy indusuy idenuncauca System (Ell 5) codes are idenuhed m the text as IXXJ

C. APPARENT CAUSE OF EVENT:

The primary Causal Factors (C/F) of this event were TRAINING /0UALIFICATION andVERBAL COMMUNICATIONS.

1. TRAINING /0UALIFICATION

Shift Supervision was not familiar with the use of OCAP 1500-2 AdministrativeRequirements for SSD Equipment and had not been trained in its use. In thisinstance, the inter-relationshi3 between an active SSD system LCO and aninoperable FP system (00S) in t1e same SSD path, was not clearly understood. Asidentified in previous Licensee Event Reports (LERs). this lack of knowledge ofthe design bases used in the development of the Fire Protection Administrative- iRequirements and SSD procedures has directly contributed to inconsistent ,applications of the requirements and consequently, a number of repeat events.

,

2. VERBAL COMMUNICATIONS

The Shift Engineer recalls requesting the Shift Foreman to review the 005 forimpact on FP and believed the Shift Foreman had reviewed the out of service forimpact on SSD LCOs. The Shift Foreman indicated that he reviewed the out ofservice for backup FP but not for SSD impact. ;

3. WRITTEN COMMUNICATIONS

Guidance for the establishment of compensatory measures is contained in several '

procedures as opposed to being consolidated in one instruction. The procedures ,used to determine affected SSD paths is complicated; however. given thecomplexity of the SSD analysis, further simplification may not be possible. ;There is no specific guidance in the 00S procedure that requires cneckingexisting fire protection LCOs for impact on SSD paths.

4. CHANGE MANAGEMENT,

OCAP 1500-2 became effective on 10/93 but the personnel required to use the ;rprocedure had not been formally trained prior to its' issuance.

D. SAFETY ANALYSIS OF EVENT:

The probability of a fire occurring in areas requiring automatic fire suppression isreduced by using procedures that control transient combustibles and the use ofignition sources. Hourly (and periodic) tours of the degraded automatic FP systemareas were performed by FP and Operations personnel. Because of the early physicaldetection probability and the reduced probability of a fire in the MG set area. thesafety significance was low and overall risk was not appreciably elevated.

i

.-

'LER254\94\003.WPF

, , - . ..

9

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rev. 2.0

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6)PAGE (3)

Year Sequenual Revision i

Numkr Numkr !*|

0|0 4 |OF| 0 | 5 )Quad Cities Unit One 0|5|0|0|0|2|5|4 9|4 - 0|0|3 -TEXT Energy Industry idenuhcanon System (Ells) codes arc xienuhed m the tett as [XXJ |

|

E. CORRECTIVE ACTIONS:

Corrective Actions to be Completed

1. Formal training with support of the FP System Engineer will be conducted forShift Engineers. Unit Supervisors and Shift Foremen to work through s)ecific

|- scenarios for taking safe shutdown ecuipment and FP equipment DOS.T1is training

' will be incorporated into initial anc requalification licensed Operator training. 'In addition a requirement for Shift Engineers and Unit Supervisors to review OCAP1500-2 with the FP System Engineer, will be added to the Shift Engineer TrainingProgram (NTS# 2541809400301).

2. In advance of the formal training, the FP System Engineer will provide interim.

"

training to all Unit Supervisors. Shift Engineers and Shift Foremen on the use ofOCAP 1500 2 (NTS# 2541809400302).

3. FP and SSD administrative procedures, and associated procedures, will be reviewed-by Operating. FP System Engineer, and Fire Marshall to enhance the proceduresfrom a human factors standpoint (NTS# 2541809400303).

4. Revise the DOS procedure to provide detailed guidance regarding review of 00Ssfor impact on SSD paths. This action was planned prior to this LER and is in theprocess of being implemented (NTS# 2541809400304).

5. Review the process for line management review of specialty training to ensurethat the training given meets the intent of the training requested(NTS# 2541809400305).

Evaluate the process for determining the app # 2541809400306).ropriate training required prior to6. issuance of a new or revised procedure (NTS

F. PREVIOUS EVENTS:

LER 92-032, Administrative Requirements For Fire Protection Not Met.

LER 1-93-015. Safe Shutdown Makeup Pump Inoperable Due To Room Cooler Inoperable:Compensatory Actions Initiated 20 Days Later Due to Inadequate Management.

LER 1-93-016. Operability Concern Based Upon Problems With OARP's and the Safe-Shutdown. Analysis.

LER 2-93-017. Ineffective Safe Shutdown Compensatory Measure Identified Due toInadequate rirewatch Inspection.

LER 2-93-020, Continuous Fire Watch Missed For The U-2 Hydrogen Seal Oil and TurbineOil Tank Deluge System.

.

LER254s94WO3.WPF,

. _ . ._ _. ~ -~ . - . . - - -_ ._. - . _ ~ . _ .. .- - .

i.

. LICENSEE EVENT REPORT (LER) TliXT CONTINUATION Form Rev. 2.0

FACILITY NAME (1,) DOCKET NUMBER (4 LER NUMBER (6)PAGE (3)

Year Sequennal Revision j

Number Number,

_ iQuad Cities Unit One 0|5|0|0|0|2|5|4 9|4 - 0|0|3 - 0|0 5 |OF| 0 | 5 |jTEXT Energy industry Idenafication System (EllSj codes are idenutied in use ten as IXXj

|

The Station has taken corrective actions in the past to prevent occurrences such asthis event. The actions have included the development of procedures to provideadministrative controls for FP and SSD equipment and training (which is still inprogress) on the administrative requirements for SSD and FP equipment. The previousactions have been ineffective in preventing recurrence. The Station has actionsplanned to enhance the procedures and training to upgrade the Stations' performanceregarding Appendix R compliance. .

i

'

G. COMPONENT Fall.URE DATA:

There were no equipment failures directly involved in this event. This report is notNPRDS reportable.

t

L

T

i >

,

9

LER254\94V)03.WPF

,

r- - - - w w e- + e , -% - - _ _ _ _ _ _ _ _ __ _ __ _ ____