05000425/LER-1990-001, :on 900103,misleading Task Sheet Leads to Inadequate Tech Spec Surveillances Found.Caused by Deficient Technical Review of Rev to Sts.Personnel Involved Counseled Re Importance of Reviewing Procedure Carefully

:on 900103,misleading Task Sheet Leads to Inadequate Tech Spec Surveillances Found.Caused by Deficient Technical Review of Rev to Sts.Personnel Involved Counseled Re Importance of Reviewing Procedure Carefully

ML20043G421
Person / Time
Site:	Vogtle
Issue date:	06/15/1990
From:	Hairston W, Odom R GEORGIA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
ELV-01757, ELV-1757, LER-90-001, LER-90-1, NUDOCS 9006200267
Download: ML20043G421 (5)

LER-1990-001, on 900103,misleading Task Sheet Leads to Inadequate Tech Spec Surveillances Found.Caused by Deficient Technical Review of Rev to Sts.Personnel Involved Counseled Re Importance of Reviewing Procedure Carefully

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(i)
4251990001R00 - NRC Website

text

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f yf Georgia PddCompanyn

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' 333 Piedtront A*nue ';

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At!Inta, Geopti $(036-'

Mmhone 404 EN D195 :

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--40 tremrtwss C+m# Parkway

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Darranghas A:atavnt 35201 i

Telei: hone 205 M&$581

. June 15, 1990 W. G. Hairston, m J Senior W.o Premdent "

Nuclear Operatrans '-

ELV-01757--

0428

' Docket'No.

50-425 U. S.1 N0 clear Regulatory Commission ATTN: ' Document Control Desk Washington, D. C.

20555 Gentlemen:

V0GTLE ELECTRIC GENERATING PLANT LICENSEE EVENT REPORT MISLEADING TASK SHEET LEADS TO INADEQUATE TECHNICAL SPECIFICl) TION SURVEILLANCES In accordance with 10 CFR 50.73, Georgia Power Company hereby submits the enclosed rev_ised report related to an event discovered on February 28,L1990.

'This revision is necessary to update the status of some of the corrective actions discussed in the original report.

~'

Sincerely, [A)

W. G.

airston, III l

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- WGH,III/NJS/gm-

Enclosure:

LER 50-425/1990-001, Revision 1 xc: Georaia Power Company Mr. C. K. McCoy L

Mr. G. Bockhold, Jr.

~Mrs R. M. Odom Mr. P.tD.. Rushton NORMS'

'U.

S. Nuclear Reaulatory Commission 1 Mr. S. D..Ebneter,.. Regional Administrator Mr. T. A. Reed, Licensing Project Manager, NRR l

Mr. '8. R. Bonser, Senior Resident Inspector, Vogtle l'

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APEOvtD OMB NO 3160 0104 LICENSEE EVENT REPORT (LER)

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V0GTLE ELECTRIC GENERATING PLANT - UNIT 2 o,s ; o io ; o ;4 l 2 5 1 lo;l014 TITLt tel MISLEADING TASK SHEET LEADS TO INADEQUATE TECHNICAL SPECFICIATION SURVEILLANCES EVENT DATE 151 LE R Nuu.tR tel REPORT DATE 171 OTHE R F ACILITIE S INVOLVED ISI MONTH DAY YEAR Yt&H l',,, 4,A b

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COMPLETE ONE LINE FOR E ACH COMPONENT F AILURE DESCRigED IN THl4 fitPORT 113) ntponiA I AC REPORTA E

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SYSTEM COM'ONENT

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On 1-3-90, a surveillance to verify containment integrity was completed and revieweo.

The surveillance verified that valves 21204U4293 and 21204U4324 were closed and secured.

Subsequently, on 2-1-90, the surveillance was repeated and valves 21204U4293 and 21204U4324 were again verified to be closed and secured.

On 2-28-90, the surveillance was again performed. During the review by the Shift Supervisor (SS), he noted that for the previous month's surveillance, only 2 of the 41-valves and flanges listed in the associated procedure were addressed. He initiated an investigation which determined that all 41 line items should have been verified on 1-3-90 and 2-1-90 as required by Technical Specif_ication-(TS) 4.6.1.1.a.

This_ specification requires that containment penetrations which are not closed by automatic isolation valves be verified closed and secured at least once per 31 days.

Therefore, the surveillances performed on 1-3-90 and 2-1-90 failed to meet the requirements of TS 4.6.1.1.a.

The principal reason for the missed surveillances was the format of the Surveillance Task Sheets (STS's) which resulted in cognitive personnel errors on behalf of the personnel involved since they were led to believe that only two valves were required to be surveilled. The STS's associated with valves 21204U4293 and 21204U4324 have been revised to delete these valve numbers and direct personnel to see the appropriate procedure. A review to identify and correct similar problems with other STS's is scheduled to be completed by 7-31-90.

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FORRIWGA.

U.S. NUCLE AA LE AULATOAV COtehel8 BION i

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PNUIREMENT FOR REPORT This report is required per 10 CFR 50.73 (a)(2)(i) because the unit operated in violation of Technical Specification (TS) requirements for surveillance testing.

B.

UNIT STATUS AT TIME OF EVENTS 4

At the timo-of the events on 1-3-90 and on 2-1-90, Unit 2 was operating in Mode _1: at 100% rated thermal power.

There was no inoperable equipment which l'

contributed to the occurrence of these events.

C.. DESCRIPTION OF EVENTS.

On 1-3-90,'a surveillance to verify containment integrity was completed and l'

reviewed, The surveillance verified that valves 21204U4293 and 21204U4324 were. closed and secured.

Subsequently, on-2-1-90, the surveillance was repeated-and again verified that valves 21204U4293 and 21204U4324 were L

closed and secured. At this time, the Shift Supervisor (SS) noted on the Surveillance Task Sheet (STS) that the surveillance was " performed satisfactory" for the two vaives listed.

On 2-28-90, the surveillance was again performed.

During the review by the SS, he noted that, for the previous month's surveillance, only 2 of the 41 valves and flanges listed in procedure 14475-2, " Containment Integrity l

Verification - Valves Outside Containment,"' were addressed.

He initiated an-l-

investigation which determined that all 41 line items should have been verified on 1-3-90 and 2-1-90 as required by Technical Specification Section 4.6.1.1.a which states:

" Primary CONTAINMENT INTEGRITY shall be demonstrated at least once per 31 J

days by verifying that all penetrations not capable of being closed by l

.0PERABLE containment automatic' isolation valves and required to be closed during accident conditions are closed by-valves, blind. flanges, or deactivated automatic valves secured in their~ positions,...".

l

- Therefore, the surveillance performed on 1-3-90 and 2-1-90 failed to meet

. the. requirements of 'TS 4.6.1.1.a.

'The review by the SS found that while the STS referenced procedure 14475-2 for use in task completion, it listed only the two aforementioned valves due i

to space. constraints.

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CAUSES OF EVENT The principal reason for the missed surveillances was the format of the STS which led the personnel involved to believe that only two valves were required to be surveilled.

The root cause for this formatting error.was an-inadequate technical review of a revision to the STS.

A contributing cause was cognitive personnel error on the part of the SS's g

f reviewing the surveillance results on 1-3-90 and 2-1-90.

They failed to adequately review the scope of the surveillonce.to ensure compliance with Technical Specification requirements. The personnel ir.volved believed that the STS's, which listed only two valves, limited the scope of the surveillance to those two valves. This error _was not the result of any-unusual characteristics of-the work location, e

O E.

ANALYSIS OF EVENT

L4 The valves in question were verified to be' locked closed when inspected on 2-28-90. A review of Maintenance Work Orders and the Locked-Valve Log 1

determined that none of the flanges in question were removed nor were the "i

valves in question manipulated.

Finally, during -the period of time L

involved, there was no event which challenged containment integrity.

Based on.these considerations, these events had no adverse impact on plant safety-or.the health and safety of the public.

F.

CORRECTIVE ACTIONS

l l.

The valves in question were verified to be locked closed when inspected I

on 2-28-90, t

2.

The STS's associated with valves 21204U4293 and 21204U4324 have been revised to delete these valve numbers and direct personnel to see procedure 14475-2, where all 41 valves and ' flanges are listed. A review I'

to identify and correct similar problems with.other STS's' was initiated.

The scope of the review was larger than anticipated.

This review and corrective actions will be completed by 7-31-90.

3.

The personnel involved have been counseled regarding the importance of attention to' detail in review of surveillance procedures.

- 4.

Licensed operator requalification training will be amended by 6-30-90 to include this report.

- 5.

Administrative controls for technical reviews of revisions to STS's have been strengthened.

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In the interim, until_ all corrective actions have been completed, direction has been given via'a nicht order to the Unit SS's to review the scope of STS's to ensure compliance with Technical Specification requirements.

1

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G.

ADDITIONAL INFORMATION

l.

Failed Components:

Le None.

2.

Previous Similar Events

LER 50-425/1989-026, dated 10-2-89.

LER 50-424/1988-012, dated 5-12-88.

3 f

The corrective actions for these LERs' addressed partially completed surveillances but the cause of the events was different than that of the events on 1-3-90 and 2-1-90.

1 3.-

Energy Industry Identification System Code:

E,

' Containment Isolation System - JM wx e,

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is, o x l

l.

NIC Pam 308A (689)