ML17289A983

LER 92-038-00:on 921014,technicians Failed to Perform Main Condenser Offgas Sample Analysis Per TS 3.3.7.12,due to Personnel Error & Inadequate Work Mgt Methods.C/A Included Counseling,Equipment Repair & Further training.W/921112 Ltr

ML17289A983
Person / Time
Site:	Columbia
Issue date:	11/12/1992
From:	John Baker, Fies C WASHINGTON PUBLIC POWER SUPPLY SYSTEM
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
GO2-92-253, LER-92-038, LER-92-38, NUDOCS 9211180100
Download: ML17289A983 (8)

Text

ACCELERATED D STRIBUTION DEMO DISTRIBUTIO

'ATION SYSTEM REGULA . Y INFORMATION SYSTEM (RIDS)

ACCESSION NBR:9211180100 DOC.DATE: 92/11/12 NOTARIZED: NO DOCKET FACIL:50-, 397 WPPSS Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH.@ARE AUTHOR AFFILIATION FIESgC ~ LE Washington Public Power Supply System BAKERPJ.W. Washington Public Power Supply System RECIP.NAME RECIPIENT AFFILIATION R

SUBJECT:

LER 92-038-00:on 921014,technicians failed to perform main condenser offgas sample analysis per TS 3.3.7.12,due to personnel error a inadequate work mgt methods.C/A included counseling, equipment repair a further training.W/921112 ltr. '0 DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR I ENCL TITLE: 50..73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

L SIZE:1 NOTES: /

RECIPIENT COPIES RECIPIENT COPIES A ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD5 LA 1 1 PD5 PD 1 1 0 DEANPW. 1 1 INTERNAL: ACNW 2 2 ACRS 2 2 0 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DET/EMEB 7E 1 ~ 1 NRR/DLPQ/LHFB10 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB 8D 1 1 NRR/DST/SICB8H3 1 1 NRR/DST/SPLB8D1 1 1 NRR/DST/SRXB'E 1 1 ERECT RGN5 FILE 01 02 1 1

1 1

RES/DSIR/EIB 1 1 EXTERNAL EG&G BRYCE P J ~ H 2 2 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHYPG A ~ 1 1 NSIC POOREPW 1 1 NUDOCS FULL TXT 1 1 NOTE TO ALL RIDS" RECIPIENTS: 0 PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCU!CLIENT CONTROL DESK.

ROOM Pl-37 (EXT. 504-2065) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!

FULL. TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 31 ENCL 31

ai WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968 ~ 3000 George Washington Way ~ Richland, Washington 99352 November 12, 1992 G02-92-253 Docket No. 50-397 Document Control Desk U,S. Nuclear Regulatory Commission Washington, D.C. 20555

SUBJECT:

NUCLEAR PLANT WNP-2, OPERATING LICENSE NPF-21 LICENSEE EVENT. REPORT. NO.92-038 Transmitted herewith is Licensee Event Report No.92-038 for the WNP-2 Plant. This report is submitted in response to the report requirements of 10CFR50.73 and discusses the items of reportability, corrective action taken, and action taken to preclude recurrence.

I Sincerely, J. W. Baker WNP-2 Plant Manager (Mail Drop 927M)

JWB/CLF/lr Enclosure CC: Mr. J. B. Martin, NRC - Region V Mr. W. Ang, NRC Resident Inspector (Mail Drop 901A, 2 Copies)

INFO Records Center - Atlanta, GA Mr. D. L. Williams, BPA (Mail Drop 399) 9211180100 921112 PDR ADOCK 05000397 S PDR

LICENSEE EVENT REPORT (LER)

ACILITY NAHE (I) DOCKET NUHB R ( ) PAGE (3)

Washin ton Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 I OF ITLE (4)

FAILURE TO PERFORM OFF GAS ANALYSIS WITHIN TECHNICAL SPECIFICATION TIME REQUIREMENTS EVENT DATE (5 LER NUHBER 6) REPORT DATE 7 OTHER FACILITIES INVOLVED 8)

HONTH DAY YEAR YEAR ,', SEQUENTIAL EVI 5 ION HONTH DAY FACILITY NAHES OCKET NUHBE RS(S)

,. NUHBER .'HBER 5 0 0 0 I 0 1 4 9 2 9 2 0 3 8 0 0 1 2 9 2 5 0 0 0 P ERAT ING HIS REPORT IS SUBHITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR  % (Cb k f th f ll I ) (11)

ODE (9)

ONER LEVEL 0.402(b) 0.405(C) 50.73(a)(2)(iv) 77.71(b)

{iD) 0.405(a)(1)(i) 50.36(c)(1) 0.73(a)(2)(v) 73.73(c) 0.405(a)(1)(ii) 50.36(c)(2) 0.73(a)(2)(vii) THER (Specify in Abstract 20.405(a)(1)(iii) X 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) clew and in Text, NRC 20.405(a)(1)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) orm 366A) 0.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPNOHE NUMBER C. L. Fies, Compliance Engineer REA CODE 5 0 9 7 7 - 4 1 4 7 COMPLETE OHE LIHE FOR EACH COMPOHEHT FAILURE DESCRIBED IH THIS REPORT (13)

CAUSE SYSTEH COMPONENT HAHUFACTURER EPORTABLE CAUSE SYSTEH COMPONENT MANUFACTURER REPORTABLE 0 NPRDS TO HPRDS SUPPLEHEHTAL REPORT EXPECTED (14) XPECTED SUBHISSIOH HOHTH DAY YEAR ATE (15)

YES (If yes, canplete EXPECTED SUBHISSION DATE) HO On October 14, 1992, chemistry technicians failed to perform a main condenser offgas sample analysis within the time required by the Technical Specifications. Technical Specification 3.3.7.12 and Table 3.3.7.12-1, Explosive Gas Monitoring Instrumentation, require an analysis of each sample within four hours of sample time. Contrary to this requirement, the sample collected at 0130 hours0.0015 days <br />0.0361 hours <br />2.149471e-4 weeks <br />4.9465e-5 months <br /> on October 14, 1992, was not analyzed until seven hours later at 0820.

Immediate corrective action was taken to analyze the gas sample. The sample was analyzed and the hydrogen level was found to be within limits.

The root cause was a work practice personnel error and inadequate work management methods.

Contributing causes included inadequate verbal communication, written direction and training.

Further corrective action included counseling, equipment repair and modification, improvements in written instructions, and further training.

The event posed no threat to the health and safety of either the public or plant personnel.

LICENSEE EVENT; REPORT ER)

TEXT CONTINUATION AGILITY NAHE (1) DOCKET NUHBER (2) LER NUHBER (8) AGE (3)

Year, Number ev. No.

Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 3 8 2 F 6 ITLE (4) r FAILURE TO PERFORM OFF GAS ANALYSIS WITHIN TECHNICAL SPECIFICATION TIME REQUIREMENTS Plan ndition Power Level - 100%

Plant Mode - 1 On October 14, 1992, chemistry technicians failed to perform a main. condenser offgas sample analysis within the time required by the Technical Specifications. Technical Specification 3.3.7. 12 and Table 3.3.7.12-1, Explosive Gas Monitoring Instrumentation, require an analysis of each sample within four hours of sample time. Contrary to this requirement, the sample collected at 0130 hours0.0015 days <br />0.0361 hours <br />2.149471e-4 weeks <br />4.9465e-5 months <br /> on October 14, 1992, was not analyzed until seven hours later at 0820.

Grab sampling of the main condenser offgas had been initiated on October 4, 1992. On that date WNP-2 entered a Limiting Condition for Operation (LCO) for explosive gas monitoring instrumentation when the Off Gas Analyzer 12A, OG-AY-12A, was taken out of service for maintenance. Grab samples are collected under Plant Procedure PPM 12.5.23A, Recombiner Sampling and Analysis. The samples are analyzed with a Carle Model AGC-111 Gas Chromatograph.

At 0130 hours0.0015 days <br />0.0361 hours <br />2.149471e-4 weeks <br />4.9465e-5 months <br /> on October 14, 1992, chemistry technicians collected the next 8 hour9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> gas sample but found the calibration of the chromatograph would not produce acceptable results. After several tries at calibration they decided at 0430 to wait for day shift relief. They thought that Technical Specification allowed them .

eight hours to analyze and felt no urgency.

Immediate rrec ive A i n At 0630 hours0.00729 days <br />0.175 hours <br />0.00104 weeks <br />2.39715e-4 months <br /> on October 14, 1992, the day shift supervisor arrived and began an investigation of the problem with the instrument. He found that two separate signals were entered into the integrator memory causing an incorrect output. After clearing the memory, he was able to perform a successful calibration of the chromatograph. The sample was analyzed by 0820 with acceptable results.

Further Evalu i n n rr iv A i n A. Further Evaluation

1. This event is being reported per the requirements of 10CFR50.73(a)(2)(i)(B) as, "Any operation or condition prohibited by the plant's Technical Specifications."

LICENSEE EVENT REPORT R)

TEXT CONTINUATION AGILITY NAME (1) DOCKET NUNBER (2) LER NUMBER (8) AGE (3)

Year Number ev. No.

Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 2 038 3 F 6 ITLE (4)

FAILURE TO PERFORM OFF GAS ANALYSIS WITHIN TECHNICAL SPECIFICATION TINE REQUIREMENTS

2. Further evaluation found the chemistry technicians use an informal guidance sheet to assure that all actions are performed in response to an LCO. The guidance reflects actual Technical Specification requirements with added cautions and information to enhance the technicians ability to meet those requirements. The actions stated in the guidance are:

"A. Either or both Explosive Monitor(s) Inoperable

1. Take grab sample every 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />.

2. Analyze each sample within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> of sample time.

3. Maintain the Chemistry LCO Log'as per PPM 12.13.33.

4. If recombiner temperature remains constant and the thermal power has not changed, grab sample frequency can be changed to 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />."

NttTE: PPM 12.13.33 quoted above refers to the Plant Procedure entitled, "Chemistry LCO Tracking" which provides a method for Tracking Limiting Conditions of Operation (LCOs) and Requirements for Operability (RFOs) requiring Chemistry Department actions or monitoring.

The technicians read step 4, which is also stated in Technical Specifications, and assumed that the analysis time was also extended to 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />.

3., Chemistry technicians have been trained on the operation of gas chromatograph equipment as part of their on-the-job training. Training on the use of the new Spectra-Physics integrator was completed early in 1992, However, Plant Procedure PPM 12.7.11, Carle Gas Chromatograph, was not updated to reflect the replacement of the Hewlett-Packard integrator which took place in June 1992.

A spare gas chromatograph is available to chemistry personnel but it has not been operational for several months. The chemistry supervisors indicated that manpower limitations have placed repair of the instrument at a low priority. Availability of this instrument may have prevented this event.

LICENSEE EVENT REPORT R)

TEXT CONTINUATION

~ ACILITY HAHE (1) DOCKET HUHBER (2) LER HUHBER (8) AGE (3) ear Number ev. Ko.

Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 2 038 0 4 F 6 ITLE (4) ~

FAILURE TO PERFORM OFF GAS ANALYSIS WITHIN TECHNICAL SPECIFICATION TINE REQUIREMENTS

5. A further review found there have been several LCOs due to problems with the explosive gas analyzers. Since 1984, there have been 56 Maintenance Work Requests (MWRs) written against Off Gas Analyzer 12A, OG-AY-12A and 67 MWRs against OG-AY-12B. Some of the MWRs were actions to improve performance of the analyzers but the majority were problems that resulted in LCOs. There have been several improvements to the analyzers that have reduced recent occurrences. A modification to replace the electronics in the analyzers is ready to work and should eliminate timer problems that have been a major concern. Maintenance and Plant Technical are aware of these problems and believe the timer modification will improve the reliability of the equipment. r

6. A root cause of this event was a work practice personnel error. The chemistry technicians did not follow their written instructions and implement the Technical Specification required actions. As a result, the gas sample was not analyzed within the time frame allowed.

A second root cause was inadequate work management methods because of management's failure to provide resources to repair the back-up sample analyses instrument and to improve the reliability of the off gas monitors in a timely manner. Means were not provided for ensuring adequate equipment quality, reliability and operability.

The following contributing causes were identified:

1) Lack of verbal communication in that the Chemistry Supervisor and Shift Manager were not notified of the problem with the gas analyzer. With the urgency of a four hour LCO, it would be prudent to immediately report any condition that could potentially result in a violation of Technical Specification.

2) Less than adequate written direction in that the guidance provided in the Chemistry LCO Log was misinterpreted by the technicians and Plant Procedure PPM 12.7.11 was not updated to reflect the Spectra-Physics integrator.

3) Less than adequate training in that the technicians on shift were not able to correct the problem with the analyzer.

B. Further rrec iv A i n

1. Chemistry technicians were counseled on this event regarding the failure to complete an offgas analysis in the allowable time and on the importance of strict compliance to Technical Specifications.

2. Action will be taken to assure backup analysis equipment is available by February 1; 1993.

LICENSEE EVENT REPORT R)

TEXT CONTINUATION AClLITY NAME (1) OOCKET NUMBER (2) LER NUMBER (6) AGE (3) ear umber ev. No.

Washington Nuclear Plant - Uhit 2 0 5 0 0 0 3 9 7 2 036 0 5 F 6 ITLE (4)

FAILURE'TO PERFORM OFF GAS ANALYSIS WITHIN TECHNICAL SPECIFICATION TIME REQUIREMENTS

3. The modification to replace the electronics in the off-gas analyzers will be completed by April 15, 1993.

4. A Chemistry Department practice will be initiated to notify the supervisor and Shift Manager of any condition that could potentially result in a violation of a Technical Specification LCO. This will be co'mpleted by January 4, 1993.

5. A clarification was added to the guidance in the Chemistry Department LCO Log for the Main Condenser Offgas Explosive Gas Monitors to make certain it is-clear that the analysis must be completed within four hours of sample time.

6. Plant Procedure PPM 12.7.11, Carle Gas Chromatrograph, will be updated to reflect the use of the Spectra-Physics integrator. This will be completed by December 1, 1992.

7. Chemistry department management had recognized the need for continued training on the'gas chromatograph as a problem and had initiated a continuing training program before this event occurred. Initial training. on the gas chromatograph will be completed by January 1, 1993.

~hi ifi There is no safety significance associated with this event. The offgas was analyzed seven hours after the.

sample was taken. The hydrogen concentration was less than one percent by volume which is within the

. Technical Specification limit of four percent hydrogen by volume.

imil r Ev n

'\

A review was conducted of previous reportable events associated with the Offgas Explosive Gas monitors and associated sampling. This review found only one previous incident where, during a LCO, offgas grab samples were not collected and analyzed within the Technical Specification allowed time. This event occurred on June 28, 1988, and.was reported in the Semi-Annual Effluent Report dated August 26, 1988.

This event was caused by inoperable sampling instrumentation which would not allow a sample to be drawn. The instrument was repaired and the sample was taken approximately one hour past the required sample time.

LICENSEE EVENT REPORT R)

TEXT CONTINUATION AGILITY NAHE (I) OOCKET NUHBER (2) LER NUHBER (8) AGE (3) ear umber ev. No.

Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 2 3 8 - 0 6 F 6 ITLE (4)

FAILURE TO PERFORH OFF GAS ANALYSIS WITHIN TECHNICAL SPECIFICATION TIME REgUIREHENTS EII Inf rm i n fT~f H~f m~mgne~n

~Lcm Off-Gas Analyzer 12A WF AY (OG-AY-12A)

AY Off-Gas Analyzer 12B (OG-AY-12B)