05000275/LER-1986-001, :on 841025,860103 & 0208,review of Surveillance Test Records Identified Missing Surveillances on RCS Temp & Containment Pressure Instrumentation Channels.Caused by Personnel Error

:on 841025,860103 & 0208,review of Surveillance Test Records Identified Missing Surveillances on RCS Temp & Containment Pressure Instrumentation Channels.Caused by Personnel Error

ML20154M748
Person / Time
Site:	Diablo Canyon
Issue date:	03/10/1986
From:	Lucket R, Luckett R, Shiffer J PACIFIC GAS & ELECTRIC CO.
To:	NRC OFFICE OF ADMINISTRATION (ADM)
References
DCL-86-066, DCL-86-66, LER-86-001, LER-86-1, NUDOCS 8603140458
Download: ML20154M748 (6)

LER-1986-001, on 841025,860103 & 0208,review of Surveillance Test Records Identified Missing Surveillances on RCS Temp & Containment Pressure Instrumentation Channels.Caused by Personnel Error

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(1)
2751986001R00 - NRC Website

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RCS TEMPERAT.RE AND CONTAINMENT PRESSURE INSTRUMENTATION SURVEILLANCES MISSED DUE TO INADEQUATE UNDERSTANDING OF THE PMTS UPDATING REQUIREMENTS EVONT DATE 153 LER NURADER (0)

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On January 3, 1986, plant personnel conducting a review of surveilli.nce test records identified missir.1 surveillances on three reactor coolant system temperature instrume%ation channels. On February 8, 1986, as part of the same review, plant personnel identified another missed surveillance on a containment pressure 'nstrumentation channel. These surveillances are required by Technical Specifications 4.3.1.1 and 4.3.2.1.

The cause of the missed surveillances was an inadequate understanding by Instrument and Control (I&C) personnel of the Preventative Maintenance Tracking System (PHTS) updating requirements (personnel error) and a lack of attention to detail.

The surveillance requirements for 'these instrumentation channels are now all met.

A review of I&C surveillance records has been performed and no other missed surveillances have been identified.

As a result of this event the following corrective actions are being taken. An I&C policy memorandum was issued to all appropriate I&C personnel to emphasize the method of correctly updating the PHTS. An independent technical review of I&C surveillance tests for completeness is now being performed prior to PHTS updating.

In addition, supplementary training is being developed for I&C personnel upgraded to supervisory status to ensure that they are knowledgeable about the correcj;g Nbh0N2 "U

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Plant Conditions

The plant was in Mode 5 (Cold Shutdown) prior to missing the surveillance on October 25, 1984 and operated in Modes 1 (Power Operation) to Mode 5 (Cold Shutdown) during this event.

II. Description of Event

A.

Event:

On January 3, 1986, plant personne! conducting a review of surveillance test records identified missing surveillances on three reactor coolant system temperature instrumentation channels (JC). On February 8, 1986, as part of the same review, plant personnel identified another missed surveillance on a containment pressure instrumentation channel (JC).

These surveillances are required by Technical Specifications 4.3.1.1 and 4.3.2.1.

The surveillance test records were being reviewed as a result of a Quality Assurance Audit Finding Report on the Updating of Preventative Maintenance Tracking System (PMTS) Records. The audit finding report identified that PMTS records had been updated with partially completed data sheets. As a result of this audit finding report, Instrument and Controls (I&C) Department personnel with the assistance of Quality Assurance personnel conducted a complete review of I&C surveillance test records on both Unit I and Unit 2.

From this review it was identified that partial calibrations performed as a result of maintenance activities were incorrectly entered as complete calibrations in PMTS records for the following instruments:

Reactor Coolant Temperature Inoperable from 10-25-84 Channc! 411/412 to 9-23-85 Reactor Coolant Temperature Inoperable from 10/31/84 Channel 431/432 to 4-22-85 Reactor Coolant Temperature Inoperable from 11-05-84 Channel 441/442 to 9-17-85 It was further identified that PMTS records were incorrectly updated to show a complete calibration when only a functional test was performed on the fo11owing instrument:

Containment Pressure Inoperable from 12-26-85 Channel 935 to 2-11-86

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B.

Inoperable structures, components, or systemsethat contributed to the event:

None C.

Dates and approximate times for major occurrences:

1.

Reactor coolant temperature instrument channel 411/412 a.

December 9, 1982:

Complete channel calibration performed b.

October 25, 1984:

Event Date - Surveillance test interval of Technical Specification (TS) 4.3.2.1 including allowable extension of TS 4.0.2.

was exceeded.

c.

September 23, 1985: Complete channel calibration performed.

d.

January 3, 1986:

Discovery Date - Review of I&C surveillance test records identified mis. sed surveillance.

2.

Reactor Coolant Temperature Instrument Channel 431/432 a.

December 15, 1982: Complete channel calibration performed, b.

October 31, 1984:

Event Date - Surveillance test interval of Technical Specification (TS) 4.3.2.1 including allowable extension of TS 4.0.2 was exceeded.

c.

April 22,1985:

Complete channel calibration performed.

d.

January 3, 1986:

Discovery Date: Review of I&C surveillance test records identified missed surveillance.

3.

Reactor coolant temperature instrument channel 441/442 a.

December 20, 1982: Complete channel calibration performed.

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November 5, 1984:

Event Date'- Surveillan::e test interval of Technical Specifiestion (TS) 4.3.2.1 including allowable extension of TS 4.0.2. was exceeded.

c.

September 17, 1985: Complete channel calibration performed, d.

January 3, 1986:

Discovery Date - Review of I&C surveillance test records identified missed surveillance.

4.

Containment pressure instrument channel 935 a.

February 10, 1984: Complete channel calibration performed.

b.

December 26, 1985:

Event Date - Surveillance test interval of Technical Specification (TS) 4.3.2.1 including allowable extension of TS 4.0.2 was exceeded.

c.

February 8, 1986:

Discovery Date - Review of I&C surveillance test records identified missed surveillance.

d.

February 11, 1986: Complete channel calibration performed.

D.

Other system or secondary functions affected:

None E.

Method of Discovery

Discovered by plant personnel conducting a review of surveillance test records in response to a Quality Assurance audit finding report.

F.

Operator Actions

None G.

Safety system responses:

None

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III. Cause of Event

A.

Immediate Cause:

4 Failure to meet surveillance requirements on Reactor Coolant Temperature Instrumentation Channels 411/412, 431/432, and 441/442 and on Containment Pressure Channel 935 as required by Technical Specifications 4.3.1.1 and 4.3.2.1.

B.

Root Cause:

1.

Personnel error (cognitive); a lack of attention to detail.

2.

Inadequate training of I E persoinel upgraded to supervisory status on PMTS updating requirements.

IV. Analysis of Event

During the time that the surveillance requirements were not met, the functional testing program (an analog channel operational test performed on a monthly interval as required by Technical Specifications 4.3.1.1 and 4.3.2.1) for these instruments indicated that the instrumentation was operating correctly. The completed channel calibrations, performed subs,equent to this period, demonstrated the instruments to be in tolerance. Thus, no adverse safety consequences or implications resulted from this event.

V.

Corrective Actions

As a result of this event the following corrective actions are being taken.

An I E policy memorandum was issued to all appropriate I E personnel to emphasize the method of correctly updating the PMTS. An independent technical review of IE surveillance tests for completeness is now being performed prior to PMTS updating.

In addition, supplementary training is being developed for I E personnel upgraded to supervisory status to ensure that they are knowledgeable about the correct method of updating the PMTS.

VI. Additional Information

A.

Failed components:

None B.

Previous LERs on similar events:

None v r er = gr r ww w=n

o PAC I F' I C GAS AND EI ECTRIC C O M PANY FG *zG, 77 BEALE STREET. SAN FRANCISCO, CALIFORNI A 94106. (415) 781 4211. TWX 910 3 7 2 0587 JAMES D. SHIPPER mcs Paestests?

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March 10, 1986 PGandE Letter No.:

DCL-86-066 Document Control Desk U.S. Nuclear Regulatory Commission Washington, D.C.

20555 Re: Docket No. 50-275, OL-DPR-80 Diablo Canyon Unit 1 Licensee Event Report 1-86-001-F Reactor Coolant System Temperature and Containment Pressure Instrumentation Surveillances Missed Due to Inadequate Understanding of the Preventative Maintenance Tracking System Updating Requirements Gentlemen:

Pursuant to 10 CFR 50.73(a)(2)(1), PGandE is submitting the enclosed revision to Licensee Event Report 1-86-001 concerning missed surveillances on reactor coolant system temperature and containment pressure instrumentation.

This revision provides supplemental information on the reactor coolant system temperature instrumentation missed surveillance and provides information on an additional missed surveillance on the containment pressure instrumentation which was identified during the review of surveillance test records.

This event has in no way affected the public's health and safety.

Kindly acknowledge receipt of this material on the enclosed copy of this l

letter and return it in the enclosed addressed envelope.

1 Sincerely, l

J.

Shiffer

/

Enclosure cc:

L. J. Chandler l

R. T. Dodds J. B. Martin B. Norton H. E. Schierling CPUC

)l Diablo Distribution

,f INPO 0752S/0042K/RhM/1761