05000254/LER-1997-001, :on 970117 & 07,discovered TS Required,Once Per Shift Channel Check Readings Not Completed within Required Twelve H Time Interval Plus 25% Max Allowable Extension. Caused by Personnel Error.Readings Performed

:on 970117 & 07,discovered TS Required,Once Per Shift Channel Check Readings Not Completed within Required Twelve H Time Interval Plus 25% Max Allowable Extension. Caused by Personnel Error.Readings Performed

ML20134G641
Person / Time
Site:	Quad Cities
Issue date:	01/30/1997
From:	Pearce L, Peterson C COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-97-001, LER-97-1, LWP-97-009, LWP-97-9, NUDOCS 9702100483
Download: ML20134G641 (6)

LER-1997-001, on 970117 & 07,discovered TS Required,Once Per Shift Channel Check Readings Not Completed within Required Twelve H Time Interval Plus 25% Max Allowable Extension. Caused by Personnel Error.Readings Performed

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(1)
2541997001R00 - NRC Website

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22 10 3Xith Astnue North Oirdos a. II.612 42-9~40 Tel 309M 4-22 a i LWP-97-009 January 30, 1997 United States Nuclear Regulatory Commission Washington, DC 20555 Attention:

Document Control Desk

Reference:

Quad Cities Nuclear Power Station Docket Number 50-254, DPR-29, Unit One Enclosed is Licensee Event Report (LER)97-001, Revision 00, for Quad Cities Nuclear Power Station.

This report is submitted in accordance with the requirements of the Code of Federal Regulations, Title 10, Part 50.73(a)(2)(1)(B). The licensee shall report any operation or condition prohibited by the Plant's Technical Specifications.

There are no commitments being made by this letter.

If there are any questions or comments concerning this letter, please refer them to Charles Peterson, Regulatory Affairs Manager at 309-654-2241, ext. 3602.

Respectfully, COMMONWEALTH EDIS0N COMPANY QUAD TIES LEAR POWER STATION l0 NA(.f

. W. Pearce Station Manager LWP/CP/plm Enclosure

]

cc:

A. B. Beach, Regional Administrator, Region III

/

R. M. Pulsifer, Project Manager, NRR j

C. G. Miller, Senior Resident Inspector, Quad Cities R. J. Singer, MidAmerican Energy Company D. C. Tubbs, MidAmerican Energy Company P. L. Piet, Licensing, Comed l

F. A. Spangenberg, Regulatory Affairs Manager, Dresden l

INPO Records Center i

9702100483 970130' PDR ADOCK 05000254 S

PDR STMORM7.L%7 A t nicom nimpany 1

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LICENSEE EVENT REPORT (LER)

Form Rev. 2.0 EiTJ%eme (1)

Docket Number G)

Page (3)

Quad Cities Unit One 0l5l0l0l0l2l5l4 1 l of l 0 l 5 Title (4)

Technied Specification required instrumentation readings were not cornpleted within the required time frequency after changing from eight hour to twelve hour stufts heccuse the consequences associated with changing shift duration were not adequately reviewed or essessed.

Event Date (5)

LER Number (6)

Report Date (7)

Other Facihties involved (8)

Month Dey Year Year Sequemial Ervinien M aa*

Dey Yost Fenlay Docket Number (s)

Number Number Names 0l5l0l0l0l l

l 0l1 0l7 9l7 9l7 0l0l1 0l0 0l1 3l0 9l7 0l5lol0l0l l

l OPERATING THIS REPORT IS $UBMilTED PUkSUANT 10 THE REQUIREMENTS OF 10C11 MODE (9)

(Check one or more of the following) (11) 1 20.402(b) 20.405(c) 50.73(a)G)0v) 73.71(b)

POWER A405(s)(1)0) 50.36(c)(1) 50.73(a)G)(v)

- 73.71(c)

LEVEL

- 20.405(a)(1)0i) 50.36(c)G) 50.73(a)G)(vii)

Other (Specify (10) 1 l0l 0

20.405(a)(1)0ii)

T50.73(a)G)(i) 50.73(a)C)(viii)(A) 7n Abstract A405(s)(1)0v) 50.73(a)C)Oi) 50.7' (a)C)(viii)(B) below and in s

- 20.405(a)(1)(v) 50.73(a)G)0ii) 50.73(a)G)(x)

Text)

LICENSEE CONIACT FOR THIS LER (12)

NAME TELEPHONE NUMBER AREA CODE Charles Peterson, Regulatory Affairs Manager, ext. 3602 3l0l9 6l5l4l.l2l2l4l1 COMPLE'TE ONE LINE FOR EACH COMPONENT F AILURE DESCRIBED IN THIS REPORT (13)

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ABSTRACT:

It was discovered on 011797, that on the 010797 day shift, with Unit One in Mode One at 100% power, some of the Technical Specification (TS) required, once per shift channel check readings were not completed within the required 12 hour1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> time interval plus 25%

maximum allowable extension. A review showed that approximately 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br /> elapsed between the recording of the night shift readings and the day shift readings.

The cause of this event was a cognitive personnel error.

The consequences associated with changing to twelve hour shifts were not adequately reviewed or assessed. The timeliness of taking readings was discussed prior to going on twelve hour shifts, but the TS requirements were not thoroughly reviewed by the procedure writer, reviewers or approver.

On 010997, (prior to discovery of this incident) administrative controls were added to the daily surveillance procedure to ensure the TS surveillance nterval is not exceeded.

There was no safety significance to the station or the health and safety of the p.ublic as a result of this event.

Each monitored parameter has four sensors to provide redundant protection. The readings were completed within approximately 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br /> of each other during consecutive twelve hour shifts and each of the readings were found within the Technical Specification limits, e

11R254i97401.WPF

LICENSEE EVENT REPCIT (LER) TEXT CONTINUATION Form R v. 2.0 F ACILITY N AME (1)

DOCKE7 NUMBEJL (2)

LER NUMBER (6)

PAGE (3)

Year Sequential Revision Number Numtwr 0l0 2 lOFl 0 l 5 f

Quad Cities Unit One 0l5lol0l0l2l5l4 9l7 0l0l1 TEXT Energy industry ident6 cation Symem (Ells) cales are ident6ed in the text as [XX)

PLANT AND SYSTEM IDENTIFICATION

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

j EVENT IDENTIFICATION: Technical 5pecification required ir,strumentation readings were not completed within the required time frequency after changing from eight hour to twelve hour shifts because the consequences associated with changing shift duration were not adequately reviewed or assessed.

l A.

CONDITIONS PRIOR TO EVENT

i Unit: One Event Date: January 7, 1997 Event Time:

1100 Reactor Mode:

1 Mode Name:

POWER OPERATION Power Level:

100%

This report was initiated by Licensee Event Report 254\\97-001.

Power Operation (1) - Mode switch in the RUN position with average reactor coolant temperature at any temperature.

B.

DESCRIPTION OF EVENT

On the 010797 day shift, with Unit Orie in Mode One at 100% power, the Technical Specification (TS) required, once per shift channel check readings were not completed within the required 12 hour1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> time interval plus 25% maximum allowable extension for the following instrumentation:

e Isolation Actuation [JM) Instrumentation, Reactor Vessel Water Level (TS table 4.2.A-1) i Anticipated Transient Without Scram (ATWS) [JC) Recirculation Pump Tr'ip (RPT) e Instrumentation, Reactor Water Level and Reactor Vessel Pressure (TS table 4.2.C-1) l On 092396, implementation of the upgraded Technical Specifications established a saecific surveillance frequency definition.

Because the Operators worked eight hour s11fts, Operating Management believed the normal Operating practice of taking readings at the beginning of each shift would meet the surveillance requirements, and decided that no procedural guidance was necessary for what time during the shift readings were to be taken. All TS required once per 12 hour1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> readings were taken three times per day and all TS required once per 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> readings were taken once per day on the same shift each day, i

IIR254\\97\\001.WPF

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LICENSEE EVENT REPOR( (LER) TEXT CONTINU ATION Form Rav. 2.0

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F AC[LnY N AME (1)

ECCKET NUMBER (2)

LER NUMBER to)

PAGE (3)

Year Sequennal Revision Number Number Quad Citie: Unit One ol5lolol0l2 5l4 9l7 0lol1 ol0 3 lOFl o l 5 TEXT E.nergy Industry identifkation System (Ell 5) codes are idenuf ed in the text as [1X) l On 010697, the Nuclear Station Operators (NS0) and the non-licensed Operators (NLO, consisting of Equipment Operators and Equipment Attendants) began working twelve hour shifts. On that day, procedure revisions were implemented changing the Operator rounds, including the TS required readings, from once per eight hours to once per twelve hours. The revision included procedural guidance that the readings l

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normally should be completed between 0700 and 1100 hours0.0127 days <br />0.306 hours <br />0.00182 weeks <br />4.1855e-4 months <br /> on day shift and between 1900 and 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> on night shift. However this was not stated as a requirement.

On 010997, an Operating procedure writer raised the question: Does the TS surveillance requirement apply to the TS required readings? Operating Management determined that TS required once per shift readings are to be taken at least once per twelve hours plus a 25% grace period, or within 15 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br /> of each other. Daily l

readings are required at least once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> plus a 25% grace period, or within 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br /> of each other. To meet the TS requirement, the surveillance procedure was revised that day to add a limitation and action requiring the TS readings to be completed in a specified time period and add a procedure step for the operator to record the time the TS readings were completed. A Problem Identification Form (PIF) was initiated to document that this completion time had not been recorded in the past to ensure TS readings were taken within the required time interval.

1 During investigation of that PIF, the Operators who were assigned to take TS readings since the start of twelve hour shifts on 010697 were asked to try to remember or estimate what time they recorded the TS required readings on those shifts. The Operators had reasonable confidence that all TS readings were taken within the required time period with one exception.

i On 011797, it was discovered that some of the Unit One Equipment Operator TS required readings for 010797 day shift were not completed within the required time interval.

The Equipment Operator stated in his interview that he was busy performing the Unit One Emergency Diesel Generator (EDG) surveillance that was started early on the shift. Between each of the hourly readings required during the EDG surveillance, the Equipment Operator took his in plant readings. He did not get to the Auxiliary Electric Equipment room or the Cable Spreading room until approximately 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br />.

A review of the security card reader history showed that approximately 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br /> elapsed between the recording of the reactor water level and reactor vessel pressure night shift readings and the day shift readings.

I LER25(37\\001.HTF

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__ _ _ _. _ =. _. _. _

l LICENSEE EVEffr REPORT (LER) TEXT CONTINUATION Form Rcn. 2 0 1

F ACILITY N AME (1)

DCrKET NUMBER (2)

LER NUMBER (6)

PAGE (3)

Year Sequential Revision Number Number Quul Cities Unit Ome 0l5l0l0l0l2l5l4 9l7 0l0l1 0l0 4 lOFl o l 5 TEXT E.nergy industry idenu6 canon $) stem (Ells) codes are idenu6ed in the text as [XX) 1 i

j C.

APPARENT CAUSE OF EVENT:

The cause of this event was a cognitive personnel error. The consequences associated with changing to twelve hour shifts were not adequately reviewed or assessed. When the surveillance procedures were revised for the upgraded TS, guidance was not provided on a time limit for taking readings because the Operators a

were working eight hour shifts.

The timeliness of taking readings was discussed prior to going on twelve hour shifts, but the TS requirements were not thoroughly reviewed by the procedure writer, reviewers or approver. The requirements of the twelve hour readings were consistent with the previous eight hour readings. The possibility of exceeding the time frequency existed with eight hour shifts, but was so remote that no specific time limits were included in the procedure.

D.

SAFETY ANALYSIS OF EVENT:

There was no safety significance to the station or the health and safety of the public as a result of this event.

Each monitored parameter has four sensors to provide redundant protection.

The readings were completed within approximately 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br /> of each other during consecutive twelve hour shifts and each of the readings i

were found within the Technical Specification limits.

E.

CORRECTIVE ACTIONS

Corrective Actions Completed:

The channel check readings were performed at approximately 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br /> on i

e 010797.

i e

On 010997, administrative controls were added to the daily surveillance procedure to ensure the TS surveillance interval is not exceeded.

The personnel involved in writing, reviewing and approving this procedure have e

been counseled.

e On 012297, the License Coordinator completed a review of procedures identified 4

as implementing significantly changed surveillance requirements in the upgraded TS to ensure that they did correctly implement the designated

. requirement. One PIF was written for a potential missed surveillance. The i

investigation determined that, for this issue, no surveillances were missed.

l i

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i LER25437201.M7F Wl

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UCENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rev. 2.0 FAclLTTY NAME. (1)

DOCKET NUMBER G)

LER NUMBER (6)

PAGE (3)

Year Sequennal Revismn Number Number Quad Cities Unit One 0l5{0l0l0l2l5l4 9{7 0l0l1 0l0 5 lOFl 0 l 5 TEXT Energy industry identificauon System (Ells) codes are idenufied in the text as (XXI F.

PREVIOUS EVENTS:

A review of previous Licensee Event Reports (LER) at Quad Cities Station Units One and Two, since 010195 concerning missed Technical Specification surveillances, missed Technical Specification action statements, missed surveillances, and Operating department cognitive personnel errors revealed the five previous events listed below:

LER 1-95-006 The Reactor mode switch was taken out of shutdown prior to completing a required Technical Specification surve.111ance due to a procedure deficiency.

LER 1-M-018 Technical Specification surveillance requirements were misinterpreted due to a conservative misunderstanding of the requirement.

LER 1-96-014 Electrical distribution weekly surveillance did not document voltage verification in accordance with Technical Specification 4.9.E. due to an inadequate procedure.

LER 1-96-024 The Control Room Heating Ventilation and Air Conditioning Isolation System was inadequately tested due to a cognitive personnel error, which resulted in credit being taken for a Technical Specification requirement by a procedure that did not contain steps to satisfy that Technical Specification requirement.

LER 1-96-017 Manual Scram taken during reactor startup when reactor water level increased following unplanned opening of all main turbine bypass valves due to an inadequate procedure.

G.

COMPONENT FAILURE DATA

There is no component failure associated with this event.

1 11R2$4Wh001EPF