IR 05000295/1990011
| ML20059N112 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 09/04/1990 |
| From: | Farber M, Lerch R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20059N110 | List: |
| References | |
| 50-295-90-11, 50-304-90-13, NUDOCS 9010100115 | |
| Download: ML20059N112 (9) | |
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U.S. NVCLEAR REGULATORY COMMISSION
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REGION III
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Reports No. 50-295/90011(DRP);50-304/90013(DRP)
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Docket Nos. 50-295; 50-304 Licenses No. DPR-39; DPR-48 i
Licensee:
Comonwealth Edison Company
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Post Office Box 767 Ch. igo, IL 60690
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L Facility Name:
Zion Nuclear Power Station, Units 1 and 2
i Inspection At:
Zion, Illinois Inspection Conducted:
April 24-through May 8 and 29,1990
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k, A-Yrict#
Inspector:
R. M. Lerch
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Approved By:
.artin J. Fa ber Chief
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Reactor Projects Section IA ate s
Inspection Summary
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Inspection from April 24 through May 8 and 29, 1990 (Reports No. 50-295/90011(DRPl; No. 50-304/90013(DRP))
Areas Inspected:
Special, unannounced inspection of concerns regarding work assignments of a licensee employee who was involved in an unmonitored discharge
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of radwaste.
Previous inspection concluded that the employee should have
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I independently verified the valve lineup.
Potential wrongdoing was investigated by the NRC Office of Investigations. The investigation concluded that the
initialed procedure that specified that the valve lineup was verified was 3 falsified record.
l Results:
No additional examples of failure by the individual-to adequately
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i perform his duties were identified.
Licensee actions to prevent recurrence
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had been taken, however, a Noti m of Violation (NOV) is enclosed with this report for the failure to adhere to procedures resulting in a failure to -
meet Technical Specific.ations, j
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900921 PD O
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DETAILS 1.
Persons Contacted i
T. Joyce, Station Manager
- W. Kurth, Production Superintendent
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W. Demo, Unit 1 Operating Engineer W. Breen, Shift Engineer W. Stone, Regulatory Assurance Supervisor i
T. Saksefski, Regulatory Assurance
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- F. Wooden,. Industrial Relations Manager
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- Indicates persons present at the exit interview.
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The inspector also contacted other licensee,nersonnel.
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2.
Background a.
Purpose This inspection was conducted to determine whether retention of-
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a non-licensed shift foreman (NSF) at his duties was appropriate.
It was found that the NSF had initialed a verification block without
performing an independen verification of a discharge valve lineup, i
resulting in en unmonitored radwaste discharge.
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Previous Inspection / Investigations t
l On March 14, 1987, a planned liquid radwaste release of the "0B"
lake discharge tank was performed.
It was later determined that the release was not monitored as required by Technical; Specification 3.11.3.a.
The licensee investigated and issued Licensee Event Report
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(LER) 295/87-007. The NRC performed an inspection on April 15, 1987,'
and confirmed the licensee's conclusions that'the release did not.
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exceed regulatory limits. The LER concluded that-one cause for the l
discharge going unmonitored was'the failure'of a-non-licensed shift i
foreman to independently verify that the valve lineup wss-proper or l
that there was flow through the radiation monitor.- Another cause was a failure by an equipment attendant to' refer to the written procedure
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501-67, " Liquid Waste Dispostl" while performing the initial lineup.
Based on LER 295/87-007 and NRC Inspection Reports-l No. 50-294/87008(DRSS); 50-304/87010(DRSS), the NRC Office of-Investigations conducted an' investigation. The investigation found that the individual knowingly and willfully failed to perform a required independent valve lineup verification and. failed to
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verify flow through a radwaste monitor while signing the checklist indicating that he had done so.
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Event Details (excerpted from inspection report 50-295/87-008; 50-304/87010)
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The following information was developed from NRC and. licensee-
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investigations of Zion liquid release R87-115 from Lake Discharge Tank "0B" on March 14, 1987.
When making planned liquid radwaste releases ~to Lake Michigan,
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the' licensee uses the applicable forms described in Zion Station Procedure ZCP 421-1, " Liquid Release Forms," which controls and
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provides documentation for releases. Attachment B to this procedure provides the forms and instructions for release from the i
Lake Discharge Tanks.
It describes the. actions,to be accomplished by everyone-involved in a release, including pre-release-verification
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by the Radwaste Foreman (an unlicensed position) that the valve lineup.is in accordance with System Operating Instruction 501-67 and
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verification " locally" of flow through PRO-5, the discharge monitor.
S01-67 specifies-the valve lineup for release to be made by the B-operator'and also instructs the. foreman to verify)the valve lineup and initial the release form (Appendix B; ZCP 421-1.
However, it did not address _ valve lineups for isolation, flushing and restoration of the discharge monitor as a prerequisite to release.
Instead, the procedure requires these to be done after each release so-that the j
monitor is ready for a subsequent release.
501-67 was not designated as an "in-hand" procedure for either the foreman.or for the B-operator.
j The radwaste foreman responsible for release R87-115 stated that.he g
did not visually verify that the valve lineup was proper nor did he
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personally observe flow through-PRO-5.
Instead, he asked the B-operator if the valve lineup was performed correctly, which received an affirmative answer. On this basis, the foreman
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initialed and checked the steps on the release form certifying that-j the verifications had been made. The foreman stated.that he accepted the affirmation of the B-operator based on her reliability over the past two years.
He stated that this was not his normal' practice and i
that he always checks if he has any doubt.
He stated his normal
practice was to make a visual verification but that he did not l
i consider it to be a requirement. Licensee management, during interviews, stated that a visual verification was intended.
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foreman also stated that it was normal practice, although not
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proceduralized, to verify flow though the monitor by observing the flow meter while opening the last of two chain locked' valves, i
i The radweste foreman on the relieving shift observed that the monitor isolation valve was closed, indicating that release.R87-115 had taken i
place without an operable discharge monitor, an apparent violation of Technical Specification 3.11.3.A.
He wrote a deviation report
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t The inoperable monitoi condition would have b'een identified if a h
proper verification of flow through PRO-5 been done by the foreman.
Release with an inoperable monitor would have been permitted by
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Technical Specification action statement 3.11.3.a if, before the t
release. two independent samples from the tank had been analyzed and
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two qualified staff members had independently verified the release rate calculations and discharge flow path valving.
However, the monitor's inoperability was not recognized and-these actions were not taken.
Tne inoperable monitor condition should also not have occurred if the post release restorations of S01-67 had been' properly done for-the release proceeding R87-115. The radwaste foreman who had been
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responsible for restoring the monitor lineup after the' previous release stated to his management that the isolation valve had been
opened as required.
j The B-operator who performed the valve lineups and made release R87-115 had about two-years experience with radwaste releases.
She stated that the pre-release valve lineup: required by 501-67 had.
been done without the procedure "in-hand":which was permissible.
i She stated that she had not closed the monitor' isolation valve as
it was not addressed in the pre-release lineup portion of S01-67 which she performed. She indicated she was not very familiar with the-valving of PRO-5 because it was normally performed by the radwaste
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foremen.
She was aware that PRO-5, unlike the alternate discharge -
monitor PRO-4, requires isolation, flushing, and restoration after
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each release.
She also stated that she had received no specific
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training on the newer PRO-5.
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Zian Station was in receipt of Regulatory Experience Report No. 87-3 dated January 13, 1987, from the_ corporate office describing a similar verification failure resulting in an inoperable-discharge monitor at Dresden on January 4, 1987. As a result of the Dresden event, a-change to S01-67 was in progress to require confirming discharge-
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monitor readiness as a prerequisite to release. The report had been routed to the radwaste foreman as required reading. At the time of
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the Zion event, according to management,~the report had been acknowledged as read by all of the radwaste foreman except the one
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responsible for making the release in question. He stated that he had recently been on vacation and was still catching up on his reading.
Technical Specification 6.2.2 requires that radiation control procedures be prepared, implemented and maintained.
Zion Station, Procedure ZCP 421-1, " Liquid Release Forms," is the governing
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procedure for release to Lake Michigan.
Page 9 of this procedure
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specifies several pre-release verifications by the radwaste foreman for Lake Discharge Tank releases including, ".... proper valve line-up according to S01-67" and "... flow thru PRO-5 locally...."
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501-67, " Liquid Waste Disposal," provides detailed valve lineups for release and requires that the' foreman verify proper lineup 'and
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initial the release form.
PRO-5 is the liquid discharge monitor for releases to the Unit 1 discharge canal.
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Contrary to these requirements,. the.radwaste foreman responsible
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for initiating release R87-115 on March 14, 1987, failed to perform
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verification of the discharge valve lineup and f ailed to verify; flow t
through the discharge monitor, PRO-5.
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Technical Specification 3.11.3.1 requires that the liquid effluent monitoring instrumentation be operable during a planned; release.,or, if inoperable. that two independent samples of the tank be analyzed ~
before release and that two qualified members of-the facility staff
. independently verify the-release path calculations and the' flow path valving.
Contrary to these requiremtnts, when discharge monitor, PRO-5.. wasi
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inoperable due to an incorrect system lineup, planned liquid radwaste release R87-115 was made with inopc-able effluent monitors and'without~
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analyses of two independent samples.
(Violation 295/90011-01;-
304/90013-01)
3.
Inspection (92701)
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This inspection was conducted by reviewing LER 295/87-007, Inspection Reports 294/87008; 304/87010, Office of Investigations ' report of
'c-investigation (Case No. 3-87-010), and procedures S01-67 " Liquid Waste.
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Disposal" and ZCP 421-1, " Liquid Release Forms".
In addition, interviews were conducted with plant management, the individual involved, his supervisors (operating engineers), another non-licensed shift foreman,
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and the Radwaste Supervisor / Planner.
The industrial relations (IR) file i
on the individual was also reviewed with the IR Manager.: A review of deviation reports was conducted to determine if any subsequent problems l
with radwaste discharge signatures had occurred, a.
The Individual
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The non-licensed foreraan (NSF) involved in the unmonitored discharge
started work at the Zion Station in 1978 and had performed the. duties i
of NSF for several years prior to this particular discharge. When j
the event was noted, the licensee investigated and concluded that l
the system lineup verification.as performed by the NSF, was
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inadequate and initiated disciplinary. action. The decision on the l
action taken wa; made by the Assistant Superintendent for Operations who is now the Production Superintendent.
It was decided to give the NSF three days off without pay and to return him to'his duties.
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The decision to return the NSF to duty.was based on discussions with his supervisors, past and present, a' review of his job performance, and a comparison of other disciplinary actions taken by the company-as a whole. The NSF's personnel file with Industr.ial Relations on site was reviewed and indicated that'to date, and with the exception of the discharge event, the NSF has a_ good record of attendance and attention to duty.
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The inspector intervlewed the NSF_'s supervisors, past and present, and reviewed his appraisals.
His appraisal indicated that he fully-met expectations. His supervisors described him as conscientious and hard working and that they had a-high, level of confidence in his work. Another supervisor who worked with him expressed similar perceptions. No one expressed any significant reservations about his work or character.
The inspector reviewed the deviation reports (DVR) involving radwaste which had been. issued since the event in order to ascertain whether the NSF had been. involved in any other problems.. A computer sort identified ten reports including the one covering the unmonitored discharge. The inspector reviewed the other.nine DVRs and found there-were none which' involved the NSF or documented other similar events.
In the interviews conducted and records reviewed, there was nothing to indicate that the NSF could not or should not continue to perform his duties. The inspector therefore has no concerns with the-individual's work performance or work assignments.-
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Corrective Actions The inspector also reviewed the corrective actions taken by the j
licensee as a result of this event.
The staticn operating instruction.
which provides the required valve lineup for discharges, 501-67 was
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revised. The revision made the procedure a " mandatory.in-hand procedure" and added specific blocks to be initialed.for the second-verification of the position of each component in the: valve lineup.
Recently completed copie:, of this procedure as well'as.the controlling procedure, ZCP 421-1, were reviewed and discussed with an NSF who had just completed them. They were filled in and initialed 'as required.
The other corrective action taken was' the disciplinary action taken with the CT.
In discussions with the licensee regarding training on requirements for. independent verifications and the mean!ng of a management signoff, the inspector found that independent verification was well described, however the licensee determined that the training for management signoffs was not,dequately formalized'and initiated a training request.
In discussions with the plant staff, the inspector did not find anyone who did not understand the requirement for these signoffs.-
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Open Items (Closed) LER 295/87-007, Lake Discharge with Radiation Monitor Isolated due to Personnel Error.
The NRC performed an inspection of a
this event on April 15, 1987, and confirmed the licensee's conclusion
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that the release did not exceed. regulatory limits. This inspection and LER review are documented in inspection report 50-294/87008;
l 50-304/87010. The inspector reviewed the' corrective actions specified t
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i in the LER and they were completed.- This item is closed.
(Closed) Violation,.295/87008-01;*304/87010-01, failure to perform L
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verification of discharge valve lineup and flow through the discharge monitor. This item is a violation for which an NOV was not issued at the time of the inspection because the event W s under consideration for escalated enforcement action and becav o an investigation by the NRC Office of investigation (01:RIII) was pending. The violation ist included in violation 295/90011-01; 304/90013-01.
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l Closed). Violation, 295/87008-02;304/87010 02,' liquid-radwaste release
made with. inoperable effluent monitors. ' An NOV was not issued at the'
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tioe of inspection because the event was under consideration for escaisted enforcement action and because an investigation by 01:RIII was pending. This violation is a direct consequence of the failure
to perform an. independent verification of the discharge path lineup-and is part of violation 295/90011-01; 304/90013-01.
(Closed) Allegation, RIII-87-A-0060 (01:RIII Case No. 3-87-10),
willful failure to verify valve lineup and radwaste monitor operability and alleged record falsification of.those verifications. The licensee reported the failure to verify the valve lineup in LER 295/87-007 and oj the licensee's investigation findings were reviewed by Region III
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inspectors in inspection report 50-295/87008; 50-304/87010.
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on these, 01:RIII investigated and substantiated these allegations (see the attached synopsis of OI:RIII Case No. 3-87-10). This
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inspection reviewed all the findings, corrective actions, and
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subsequent performance of the individual involved. Based on the j
conclusions of this inspection, no further action is~ required and
this item is closed.
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Conclusion
Inspection findings indicate that this was an isolated occurrence and the underlying event was of minor safety significance.
The licensee identified i
the problem and its root cause and reported it as required. The corrective
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actions taken by the licensee appear adequate to prevent recurrence of the H
event. The individual involved accepted responsibility from the beginning'
and has exhibited honesty and regret regarding his role. He has performed without problem since then. The inspector reviewed the licensee's corrective actions and found them appropriate to the circumstances. The
inspector has no further concerns in this' area.
Based on this inspection,
the oliginal violation is being issueo with a Notice of Violation (NOV)-
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in this report, a
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! Exit Int'erview (30703)'
The inspector met with licensee. representatives-(denoted in Paragraph-1)-
throughout the inspection period and at the' conclusion of the inspection
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to sunnerize the scope:and findings of. the inspection activities.- The licensee acknowledged the -. inspectors' concents...The: inspectors also
' discussed the likely informationalicontent of the inspection report with?
regard to documents or processes reviewed'bycthe. inspectors during the-
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i_nspection'. The licensee did not. identify any such documents or-
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processes.- as' proprietary.
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-SYNOPSIS
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On May 20, 1987,_the'N1 Office of Investications (01:RIII) received a. Request t
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inspection whiv'was' performed after NRC:RIII was1 notified of a problem with a
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liquid radwaste: release at the Zion Generating Station on March 14, 1987.
Information provided by the licensee indicated that the radwaste foreman i"
failed to perform a requirea independent l discharge valve lineup verification'
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trd failed tc verify the sample flow discharge monitor operability.in
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violation of technical specifications, while signing. the checklist; indicating that he had done so.
Information developed during'the-hRC:RIII-inspection'
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L indicated that there was a discrepancy between.the radwaste _ foreman's stated.
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- p(erception of verification.and the statement in the Licensee Event _ Re L
LER). The matter was referred to 01:RIII: to: determine,1f the' radwasto J
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foreman e other licensee emphyees willfully violated requirements and willfully falsified the checklist record.
i A licensee investigation of the' event concluded that the principal cause of y
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tNlt event was personnel error hy the radwaste-foreman,Ewho was:respcnsible L
for managemen* verification of the pre-release valve lineup.
Contrary to the :
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i procedure requirements, the radwaste fereman failed to personally verify either the valve lineup or the flow through the radwaste monitor.
Instead,
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the radwaste foreman had asked the operating equipment'atter. dant (0EA) to'
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3rify the radwaste monitor status, and the-radwaste foreman assumed that the
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CEA had performed the valve lineup correctly. ~The'lir.ensee stated that-all.
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unlicensed shift foremen a're trained to persons.11y. vorify valve'linebps.on I
effluent releases, particularly when a management! Mgnaturelis required by
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procedure, as was:the :ase in this event.
The 01:RIII investigation substantiated that the shift radwaste foreman
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willfully failed to perform a required independent valve lineup verification
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and failed to verify flow through the conitor, while signing the-checklist
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a indicating that he had dcne so. The radwaste foreman admitted that he-had not personally verified the lineup, but rather had verified by receiving ' verbal
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affirmation-from the OEA, which the'raevaste foreman' felt'was_not a_ violation
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of the procedure.
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The radwaste foreman had,no recollection of his training with regard to
.4 management verification, yet documentation was provided which substantiated
that the radwaste foreman had received training on two separate occasi:,ns (one as-recent as two weeks prior to the event) which addressed'the-issue of'
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failu-to properly perform verificttions. The radwaste-foreman accepted the l
blame for the valving error, since ]t had been his ;esponsibility te have verified the lineup. There was no evidence to substantiate that other
L licensee employees were involved in this mtter.
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L Case No. 3-87-01'O
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