05000327/LER-1993-001, :on 930124,Unit 1 Ice Bed Temperature Recorder in MCR Declared Inoperable.Caused by Ineffective Communication.Appropriate Personnel Involved W/Event Have Been Counseled

:on 930124,Unit 1 Ice Bed Temperature Recorder in MCR Declared Inoperable.Caused by Ineffective Communication.Appropriate Personnel Involved W/Event Have Been Counseled

ML20044B675
Person / Time
Site:	Sequoyah
Issue date:	02/23/1993
From:	Fenech R, Whittemore C TENNESSEE VALLEY AUTHORITY
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-93-001, LER-93-1, NUDOCS 9303010258
Download: ML20044B675 (10)

LER-1993-001, on 930124,Unit 1 Ice Bed Temperature Recorder in MCR Declared Inoperable.Caused by Ineffective Communication.Appropriate Personnel Involved W/Event Have Been Counseled

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications 10 CFR 50.73(a)(2)(iv), System Actuation 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability 10 CFR 50.73(a)(2)(i) 10 CFR 50.73(a)(2)(viii)(A) 10 CFR 50.73(a)(2)(ii) 10 CFR 50.73(a)(2)(viii)(B) 10 CFR 50.73(a)(2)(x)
3271993001R00 - NRC Website

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i Tennessee Vahey Authority. Post Ottce Box 2300, Sadd,-Da!ry. Tennessee 373797000 Robert A Fenech l

Mce Presiae.it Sequovah NaClear Plant l

Feb ruary 23, 1993 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk l

Washington, D.C. 20555 Gentlemen:

TENNESSEE VALLEY AUTHORITY - SEQUOYAH NUCLEAR PLANT UNIT 1 - DOCKET i

NO. 50-327 - FACILITY OPERATING LICENSE DPR LICENSEE EVENT REPORT (LER) 50-327/93001 i

The enclosed LER provides details concerning the failure to properly perform a technical specification (TS) surveillance requirement verifying ice condenser operability.

l This event is being reported in accordance with 10 CFR 50.73(a)(2)(i)(B) as an operation prohibited by TSs.

t Sincerely, Nb Robert A. Fenech Enclosure cc: See page 2 f

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i 9303010258 930223 fi PDR ADOCK 05000327 I

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U.S. Nuclear Regulatory Commission Page 2 February ~23, 1993 cc (Enclosure):

INPO Records Center Institute of Nuclear Power Operations 1100 Circle 75 Parkway, Suite 1500 Atlanta, Georgia 30339-3064 Mr. D. E. LaBarge, Project Manager U.S. Nuclear Regulatory Cormnission One White Flint, North 11555 Rockville Pike Rockville, Maryland 20852-2739 NRC Resident Inspector Sequoyah Nuclear Plant 2600 Igou Ferry Road Soddy-Daisy, Tennessee 37379-3624 Mr. B. A. Wilson, Project Chief U.S. Nuclear Regulatory Commission Region 11 101 Marietta Street, NW, Suite 2900 Atlanta, Georgia 30323-0199

NRC Form 366 U.S. NUCLEAR REGULATORY COMMISSION Approved OHB No. 3150-0104 (6-89)

Expires 4/30/92 LICENSEE EVENT REPORT (LER)

FACILITY NAME (1) l DOCKET NUMBER (2) lPAGE(3)

_Segunsch_!btlfar Plant. Unit 1

_jQJMDjDjDj3_j2 l711lDfj_.0]_J TITLE (4) Ice Bed Monitoring Surveillance Requirement Time Interval Exceeded Because of Poor Communications EVENT DAJ (5) l LER NUMBER (6) l REPORT DATE (7) 1 OTHER FACILITIES INVOLVED (8) l l

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l l SEQUENTIAL l l REVISION l l

l l FACILITY NAMES lDOCKETNUMBER(S)

H0t1THj_DAYlYEARlYEARI l NUMBER l l NUMBER lHONTHl DAY lYEAR l 10lddQJ01 l l l

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l HDDE l l_1Chettsne_c.r_msre et.the_lollsw_ing)(11) i (9) 11 1 _l20.402(b) l_l20.405(c) l__l50.73(a)(2)(iv) l_l73.71(b)

POWER l l_l20.405(a)(1)(i) l_l50.36(c)(1) l._l50.73(a)(2)(v) l_l73.71(c)

LEVEL l l___l20.405(a)(1)(ii) l_l50.36(c)(2) l_l50.73(a)(2)(vii) l_l0THER(Specifyin i

(10) 1110__ILl__l20.405(a)(1)(iii) lX1l50.73(a)(2)(i) l_l50.73(a)(2)(viii)(A) l Abstract below and in l__l20.405(a)(1)(iv) l_l50.73(a)(2)(ii) l_l50.73(a)(2)(viii)(B) l Text, NRC Form 366A) l 120.405(a)(1)(v)

I 150.73(A1(2)(iii) l 150.73(a)(2)(x) l LICENSEE CONTACT FOR THIS LER (12)

NAME l

TELEPHONE fQMBER lAREACODEl C. H. Whittemore. Comglianae Licensino l_bI115l8I413l-l71211 10 COMPLIJE ONE LINE FOR EACH COMPONENT FAILURE DESCBIRED IN THIS REPORT (13) l l

l l REPORTABLE l l

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l l YES (If ves. comolete EXPECTED SUDMISSION DATE) l X l NO I DATE (15) ! l l l l l

ABSTRACT (Limit to 1400 spaces, i.e., approximately fif teen single-space typewritten lines) (16)

On January 24, 1993, at 0218 Eastern standard time, with Unit 1 in Mode 1 operating at 100 percent power, the Unit 1 ice bed temperature recorder in the main control room (MCR) was declared inoperable. After obtaining informal readings and observing erratic recorder operation, Limiting Condition for Operation (LCO) 3.6.5.2 was entered. With the ice bed temperature monitoring system inoperable in the MCR, ice bed temperatures at the local monitoring panel inside containment must be obtained every 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. However, neither the MCR surveillance nor the local surveillance were completed within the required technical specification surveillance time. The cause for the missed surveillance was poor communications and failure to properly complete the surveillance package. The validity of prior control room data and the urgency of obtaining local readings were not consistently understood or communicated. The local surveillance was completed satisfactorily, and the MCR ice bed temperature recorder was subsequently replaced and declared operable. Corrective actions include review of lessons learned with Operations personnel and development of a more formal method for initiating a conditional surveillance.

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NRC form 366(6-89)

NRC Tbrm 366A U.S. NUCLEAR REGULATORY COMMISSION Approved OMB No. 3150-0104 (6-89)

Expires 4/30/92 j

LICENSEE EVENT REPORT (tER)

TEXT CONTINUATION i

FACILITY NAME (1) lDOCKETNUMBER(2)j LER NUMBf!Lf6) l l

PAGE f3) l l

l l SEQUENTIAL l l REVISION l l l l l Sequoyah Nuclear Plant. Unit 1 l

lYEAR I l NUMBER l

}_ NUMBER _1 l l l l IMMMMM3_lL1719131-1 o I o 1 1 1-I o I o I ol 2torl of a TEXT (If more space is required, use additional NRC Form 366A's) (17)

I.

P1 ANT CONDITIONS Unit 1 was operating at approximately 100 percent power in Mode 1.

II.

DESCRIPTION OF EVENT

A.

Event On January 24,1993, at 0218 Eastern standard tinie (EST) af ter obtaining the ice condenser (EIIS Code BC) ice bed temperatures, the Unit 1 ice bed temperature recorder (EIIS Code TR) in the main control room (MCR) was administrative 1y declared inoperable, and Limiting Condition for Operation I

(LCO) 3.6.5.2 was entered. A work request (WR) to troubleshoot the recorder was initiated along with the requirement to obtain temperature readings from the local panel inside containment every 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />.

As a result of poor communication regarding assessment of data validity and recorder operability, the temperature data was not transferred onto the surveillance instruction (SI) data sheet to be evaluated and was discarded.

This miscommunication also resulted in not obtaining local readings for the midnight shift surveillance performance package until after the surveillance interval was exceeded. This was recognized by the shift operations supervisor (SOS) on day shift at approximately 1000 EST when he discovered that no data had been recorded in the midnight shift SI package. Without a documented surveillance performance to verify ice condenser temperatures below the TS i

limit, the SOS additionally entered LCO 3.6.5.1.

The conditional surveillance was performed, and LCO 3.6.5.1 was exited at 1143 EST on January 24, 1993.

Ice bed temperature readings were taken at the local panel, as required, until the ice bed temperature recorder was returned to service, and LCO 3.6.5.2 was exited at 2114 EST on January 25, 1993.

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B.

InopfrahlcltIncinteru_ Components. or. Systems That Contribmied. to the_EYent l

On January 24, 1993, a WR was written to troubleshoot the ice bed temperature monitoring recorder on Unit 1.

The recorder print head was reported to be l

swinging and erratically stamping. Additionally, the instrument mechanics (IMs) found the recorder to be out of calibration on 'an average of 6 degrees Fahrenheit (F) low with a maximum deviation of 6.8 degrees F low.

C.

Dates _and Times _of_ Major Occurrences I

January 23, 1993 Ice bed temperature readings were taken, using the 1730 EST recorder in the MCR.

2400 EST The recorder started to erratically stamp. This is based on review of the strip chart taken from the recorder.

NRC form 366(6-89)

P NEC fo'rm 366A U.S. NUCLEAR REGULATORY COMMISSION Approved OMB No. 3150-0104 (6-89)

Expires 4/30/92 LICENSEE [VDfT REPORT (tER)

TEXT CONTINUATION FACILITY MAME (1) lDOCKETNUMBER(2)l_

LER NUMBER (6) l l

PAGE (3) l l

l l SEQUENTIAL l l REVISION l.l l l l Sequoyah Nuclear Plant. Unit 1 l

l YEAR l. l. NUM ER I I NUMEd l l l l 10151DjalouJLIL12J3J=D I O I 1 1_LD_L 0 DL3]DLLaLfL i

TEXT (if more space is required, use additional NRC forn 366A's) (17) f January 24, 1993 The auxiliary unit operator (AUO) started taking ice bed 0200 EST temperature readings from %e recorder and noticed that it was hard to read because it was behaving erratically.

0210 EST The ADO and non-licensed unit operator (UO) worked-together to record temperature readings on a separate piece of paper. The erratic operation of the recorder was brought to the attention of the assistant shift operations supervisor (ASOS) and the SOS.

0218 EST The SOS declared the recorder inoperable and entered LCO 3.6.5.2.

The SOS considered the data just taken valid. A WR was initiated to troubleshoot the recorder. The WR indicated that local readings were required every 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> starting at 0218 EST.

023J "3T The SOS notified the shift support manager (SSM) that a WR to repair the recorder had been initiated.

I 0500 EST The SOS communicated to the SSM that tne ice bed temperature readings at the local panel inside containment needed to be taken by 0700 EST.

0520 EST The SSM went to the Maintenance Instrument Group shop and told the IMs that they must take local readings.

0630 EST Following delays in identifying and locating a conditional surveillance package, the SOS and SSM agreed that day shift should perform the SI as soon as possible.

0700 EST The night shift senior reactor operator and ASOS assumed that readings were being taken locally. The shift log l

surveillance package was approved without the ice bed i

temperature readings recorded. The Appendix E data sheet was noted with a deficiency and recorded in the deficiency log.

l Shift turnover was conducted, and the inoperable recorder was discussed by the SOSs..The conditional surveillance was not signed in on the Operations test awareness log.

0800 EST The day shift IMs received the conditional surveillance package from the Technical Information Center. The IMs j

proceeded to the MCR to see if the recorder could be i

repaired quickly so that containment entry would not be required. The IMs believed that the SI was due by i

1400 EST.

NRC Iorm 366(6-89)

.U.S. NUCLEt.R REGULATORY COMMISSION Approv d OMB No. 3150-0104 (6-89)

Expires 4/30/92.

LIEENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITY NAME (1)

]DOCKETNUMBER(2)}

LER NUMBER (6) l l

PAGE (3) l l

l l SEQUENTIAL l l REVISION l l l l l Sequoyah Nuclear Plant. Unit 1 l

JYEARl I NUMBER I I NUMBER I l l l l [QJ510101013 12 17 19 13 l-l 0 1 0 1 1 l-l 0 l 0 1 01 4l0Fl 01 8 i

TEXT (If more space is required, use additional NRC Form 366A's) (17) 0830 EST The surveillance interval plus a 25 percent extension was exceeded.

0900 EST After the determination that the recorder repair could not be accomplished quic1cly, the IMs obtained approval to begin the conditional performance. Delays were encountered in entering containment.

1000 EST The day shift SOS was unable to find the completed shift log surveillance data sheet with ice bed temperatures from the previous shift and entered LCO 3.6.5.1-for the missed surveillance.

1143 EST The conditional surveillance was completed, and LCO 3.6.5.1 was exited.

January 25, 1993 The ice bed temperature recorder was replaced, and the 2114 EST monitoring system was declared operable. LCO 3.6.5.2 was exited.

D.

Other Systems or Secondary Functions Affected

None.

E.

Ec_thod of Discovery This event was discovered at 1000 EST on January 24, 1993, when the day shift SOS discovered that no data had been recorded on the midnight shift surveillance performance package. A review of the UO logs revealed that the previous ice bed temperature readings had been recorded at 1730 EST on January 23, 1993. Sixteen and one-half hours had elapsed, and this was recognized as a failure to complete the TS surveillance within the required TS i

timeframe.

F.

Dparator Action When the SOS discovered that the surveillance time interval for monitoring the ice bed temperatures had been exceeded LCO 3.6.5.1 was entered..The conditional SI was completed shortly thereafter, and LCO 3.6.5.1 was exited.

The conditional S1 was performed at least once every 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> until the ice bed temperature monitoring recorder was replaced and the monitoring system was declared operable. LCO 3.6.5.2 was then exited.

NRC Fom 366(6-89)

I

NRC F'rm 366A U.S. NUCLEAR REGULATORY COMMISSION Approved OMB No. 3150-0104 o

(6-89)

Expires 4/30/92 LICENSEE EVENI REPORT (LER) t TEXT CONTINUATION FACILITY NAME (1) lDOCKETNUMBER(2)I LER NUMBER (6) l I

PAGE f3) l l

l l SEQUENTIAL l l REVISION] l l l l Sequoyah Nuclear Plant, Unit 1 l

hEARI l N @ ER l l NUMBER l l l l l 10}5j010101312 17 1913 l-l 010 l 1 1-101 0101Sl0Fl0l8 TEXT (If more space is required, use additional NRC form 366A's) (17)

G.

Safety SystegtlesRons.ch.

Not applicable - No safety system responses were required.

III.

CAUSE OF EVENT

A.

hatediale_Cause The MCR ice bed temperature monitoring recorder was behaving erratically and was declared inoperable. Data taken just before declaring the monitor inoperable was not recorded in the surveillance package and local readings were not taken before the surveillance interval was exceeded.

B.

Rottt_CausE The root cause was ineffective communication.

The SOS did not clearly communicate his assessment that the data taken at 0218 EST was valid for the purpose of completing the surveillance for the current surveillance interval; therefore, the data was discarded with the ASOS assuming that local readings would be taken for that performance. This miscommunication led to lack of common understanding of the need to obtain local readings before the current surveillance interval expired.

C.

Contrihnting Factor The surveillance data sheet format was not considered conducive to direct transfer of recorder data points during numerical stamping. This led to a practice of recording data on separate pieces of paper for future transfer to the surveillance package. Failure to record the data on the surveillance data sheet prevented the data from being reviewed, evaluated, and appropriately dispositioned and contributed to not detecting the differences in understanding before the surveillance interval expired.

Additional contributing f actors include the delays encountered in obtaining the.

local readings. Ilowever, had the understandings been consistent ind effectively communicated, the overall activity may have been expedited before the surveillance interval expired.

NRC Form 366(6-89)

e NRC r'orm 366A U.S. NUCLEAR REGULATORY COMMISSIDH Approved OMB Ho. 3150-o104 (6-89)

Expires 4/30/92 LICENSEE LYLNT REPORT (LER)

TEXT CONTINUATION FACILITY NAME (1) lDOCKETNUMBER(2)l LER HUMBER (6) l l

PAGE (3) l l

l l SEQUENTIAL l l REVISION l l l l l Sequoyah Nuclear Plant. Unit 1 l

jf1ARl l NUMBER l I NUMBER I l l l j 1015191910J3_J21719131-1 o I o I i 1-1 o I o l of 6 lori al 8 TEXT (If more space is required, use additional NRC Form 366A's) (17)

IV.

ANALYSIS OF EVENT

The ice condenser is a passive safety system that acts automatically in conjunction with other engineered safety features to limit containment pressure during a worst I

case loss of coolant accident. There are not any engineering safety system signals or reactor protection system signals generated by the ice bed monitoring system or i

the temperature recorder instrument loop. Furthermore, there were not any reactor or system transients during the surveillance period, and the ice bed temperature never exceeded the TS upper limit of 27 degrees F.

The ice condenser was t

unimpaired and was available to perform its intended safety function if an accident had occurred.

Therefore, this event did not adversely affect the health or safety of plant personnel or the public.

V.

CORRECTIVE ACTIONS

A.

Ingnediate CorrecliYe_Attion At 1000 EST, when the day shift SOS was unable to find the completed shift log

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surveillance ice bed temperature data sheets from the previous shift, he entered LCO 3.6.5.1 for the missed surveillance. The conditional surveillance was successfully completed when the ice bed temperatures were taken at 1143 EST, and LCO 3.6.5.1 was exited.

B.

Corrective Actions to PERYent_Rs_curr_ence 1.

The appropriate personnel involved with this event have been counselled on the importance of clear communications. Coaching and counselling has also been conducted with the other SOSs.

i 2.

The Operations superintendent will review this incident during week two of l

the 1993 licensed operator requalification training as an example of how inadequate connunications can lead to a significant event. Specific areas of review regarding this event will focus on the following areas:

i data taken and not recorded in the SI package i

a.

b.

data taken on unofficial data sheets working around procedures that are deficient or not user-frirmdly

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c.

d.

command and control e.

shift turnover f.

journal-keeping g.

clear and concise connunication 3.

A more formal method of initiating conditional sis that does not depend l

solely on verbal connunications will be developed and implemented.

I i

NRC Form 366(6-89) f

NRC T6rm 366A U.S. NUCLEAR REGULATORY COMMISSION Approved OMD No. 3150-0104 (6-89)

Expires 4/30/92 LICENSEE LVINT REPORT (tLR) l TEXT CONTINUATION i

FACILI1Y NAME (1) lDOCKETNUMBER(2)j LULJNtIDULib) l I

PASL.13) l l

l l SEQUENTIAL l l REVISION l l l l l Sequoyah Nuclear Plant, Unit 1 l

jKAjLj l NQMQLR l_ jjMMDLRJ l l Ii 10151010]Dja_lLil_j9J31-101 Oj 1 l-l D l 0 l_0l_IlotLoJJL TEXT (If more space is required, use additional NRC Form 366A's) (17) 4.

The SI for Units 1 and 2 shif t log surveillance has been revised to make the Appendix E data sheet format more user-friendly where the personnel r

recording ice bed temperatures can record the data directly on the data sheet.

s VI.

ADDITIONAL INFORMATION

i l

A.

Eailedlomponents l

The failed ice bed temperature recorder was a Westronics Model MllE.

B.

hevdouslysnis i

A review of several recent events with causal factors similar to or identical to this event were identifled and examined.

LER 50-328/91005 reported a failure to perform a conditional heat balance calorimetric calculation within the required timeframe following the failure of the plant process computer.

The cause of this event was attributed to inadequate communications between Operations personnel and the Maintenance personnel responsible for performing the conditional surveillance.

LER 50-327/92006 reported a failure to properly verify RCS flow values against technical specification acceptance criteria.

The cause of this event was attributed to the failure of Operations personnel to refer to acceptance criteria contained in a separate procedure than the i

shiftly surveillance package. LER 50-328/92006 reported the failure to perform a conditional surveillance of cold Icg accumulator (CLA) boron concentration following volume changes in the CLA within the required timeframe. The event was caused by inadequate communications between Operations personnel and Chemistry personnel. LER 50-328/92007 reported the inappropriate entry into i

Mode 4 with both trains of the containment spray system inoperable. This event f

was caused by a failure to properly implement the configuration control process.

i The four events described above reflect instances of unacceptable performance by Operations personnel in the areas of communications, shift turnover, logkeeping, and use of procedures.

In two of the events, this performance, in conjunction with unacceptable performance by interfacing organizations, resulted in failures to adequately perform conditional surveillances within required timeframes. As evidenced by.this current event, previous corrective actions have not been effective in precluding these types of events.

Specifically, for the missed conditional surveillances, previous actions focussed on improved personnc1 performance, i.e., improved communications, or j

tools specific to the performance of calorimetric calculations.

Because efforts directed at improved communications have not been as effective as desired, the current event was not prevented. The current corrective action to develop a formal process for initiating conditional surveillances will provide a tool that is not solely dependent on communication practices.

NRC Fonn 366(6-89)

e flRC Fdrm 366A U.S. tJUCLEAR REGULATORY COMMIS$10tl Approved OMB tJo. 3150-0104 (6-89)

Expires 4/30/92 LICENSEE EVENT REPORT (ELR)

TEXT C0f1TItJUATI0fJ FACILITY tJAME (1) l DOCKET IJUMBER (2) j_

LER_JJUMBER_16)_1 l.

PAGE_13)

I l

l l lSEQUEtJTIALl lREVISI0fJl l l l l Sequoyah tJuc1rar Plant Unit 1 l

} YEAR _1_1_FUMDER l_ l t4UMDLR._} l l l l lo15101olol3_12JL19JLL_LDJJLLL1-1 0 1 0I.o_Lelofj_ol_o_

1 EXT (It more space is required, use additional IJRC form 366A's) (17)

As described above, previous corrective actions associated with personnel performance have not yet obtained the desired results. These efforts have not f

been wholly effective because of ineffective line management involvement in the communication and enforcement of expectations. Recent line management changes in the Operations organization, in conjunction with increased senior site management oversite, are expected to provide steady improvements in personnel performance.

VII.

COMMITMENTS

{

l 1.

A more formal twthod of initiating conditional sis that does not depend solely on verbal communications will be developed and implemented by April 19, 1993.

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2.

The Operations superintendent will review this incident during week two of the 1993 licensed operator requalification training as an example of how inadequace communications can lead to a significant event.

This will be accomplished by a

April 19, 1993, i

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IJRC form 366(b-89) 1