ML17300A866

LER 87-007-00:on 870423,time Interval for Sampling Concentration of Hydrogen & Oxygen in Gaseous Radwaste Sys Exceeded,Contrary to Tech Spec 3.3.3.9.Caused by Cognitive Personnel Error.New Form Used to Aid personnel.W/870520 Ltr

ML17300A866
Person / Time
Site:	Palo Verde
Issue date:	05/20/1987
From:	Bradish T, Haynes J ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
192-00207-JGH, 192-207-JGH, LER-87-007-01, LER-87-7-1, NUDOCS 8705270654
Download: ML17300A866 (7)

Text

REGULATO NFORMAl CON DISTRIBUTION TEM (R IDS)

ACCE>)S I QN NBR: 8705270654 DOC. DAl E FAC CL: STN-50-529 Palo Verde Nuclear

'7 /05/20 NOTAR ZED: KQ Qt~tioni t I

Uni 2I Arizona Pub li DOCKET 0500052'UTH.

Bt-NAME AUTHOR AFFILIATION BRADISH T. R. Ar'izona Nuclear Po'cr ProJect ( former lg Ari zona Public Serv HAYNESI J. G. Arizona Nuclear Po er ProJect (formerly Ari zona Public Serv REC IP. NAME RECIPIENT AFFILIAl SUB JECT: LER 87-007-00: on 870423I time inter val f or sampling concentration of hydrogen ~r oxygen in gaseous radwaste sgs exceeded> contrary to Tech Spec 3 3. 3. 9. Caused bg cognitive personnel error. New form used to aid personnel. W/870520 1 tr.

DISTRIBUTION CODE: IE22D COPIES RECEIVED: LTR J ENCL 'IZE:

TITLE: 50. 73 Licensee Event Report (LFK>I Incident Rpti etc.

NOTES:Standardized plant. M. Davisi N~R: iCg. 05000529 RECIPIENT COPIES REC IP I EN 1 COPIES ID CODE/NAME LTTR ENCt. ID CODE/h! AME LTTR &t "L PD5 LA 1 1 PD5 PD 1 LICITRA E 1 1 D,VIS M 1 INTERNAL: ACRS MICHELSON 1 1. ACRS MOELLER 2

• EOD/DOA 1 AFQD/DSP /ROAB 2 e' AEOD/DSP/TPAB 1 1 DE>)RO NRR/DEST/ADE 1 0 tirtR/DEBT/ADS 1 0 NRR/DEBT/CEB 1 t!HR/DEBT/ELB 1 NRR/DEBT/ I CBB 1 1 l!~R/DEBT/ME'H NRR/DEST/MTB 1 tiwR/DEST/PSH NRR/DEBT/RSB 1 1 t!NR/DEBT/BGB 1 NRR/DLPG/HFB 1 t!rtR/DLPQ/GAB NRR/DOEA/E*B 1 t!wR/DREP/R*B 1 NRR/DREP/RPH 2 t!H t S/ I LRB 1 1' NRR/PMAS/PTBB 1 REC F IL 02 PES DEPY GI 1 1 lw LE 01 EXTERNAL: EG8(G GROHI M 5 5 H ST LOBB Y WARD LPDR 1 t!rtC PDR 1 1 NSIC HARRIBI J 1 t!SIC t'IAYSI 0 h~OTEB:

TOTAL NUMBER OF COP I ES REQUIRED: L TIR O'; ENCL 42

NAC Form $ 40 US. NUCLEAR REOULATORY COMMISSION (90$ l AppRDYED DMS No. $ 1400104 LICENSEE EVENT REPORT {LERI EXPIRES: Sl$ 1(44 FACILITY NAME (II DOCKET NUMBER (2)

Palo Verde Unit 2 0 5 0 0 0 5 2 9 1 OFO 3 TITLE lel Personnel Error Causes Chemistr Sam le Interval to be Exceeded EVENT DA'TE (5) LER NUMBER (4) REPORT DATE (7) OTHER FACILITIES INVOLVED (4)

SEQUENTIAL II4 vnelON FACILITY NAMES DOCKET NUMBER(SI MONTH DAY YEAR YEAR Scc) NUMOER I ee MUM44R MONTH OAY YEAR N/A 0 5 0 0 0 0 4 387 8 7 007 0 0 0 5 2 0 8 7 N/A 0 S 0 0 0 THIS REPORT IS SUBMITTED PURSUANT 7 0 THE REQUIREMENTS OF 10 CFR g: (Chectr one or mne of the lollowlnpl (11 OPERATINO MODE (4) 20A02(hl 20A04(c) 50.7$ 4) 12) Dr) 7$ .71(lr)

~ OWER 20A05(e) (I I(0 50.$ 4lc) III 50.7$ 4)(2)(vl 7$ .7) lcl LEYEL 1 0 0 20AOI(e) (I)IP) 50.$ 4(el (2) 50.7$ le)(2)(r5) OTHER (Specify ln Abc trect below enrf in Feet, ffl)C Form 20A05(e) (1)(ill) 50.7$ (e) (2((l) 50.7$ 4)(2) (rill)(A) JPEA) 20.405(el(1 Hlrl 50.7$ 4)(2)IQ) 50.7$ (el(2) IrIS)(5) 20.405 (I I (I) (v) 50.724) 12) I ill) 50.7$ (e) (2) 4(

LICENSEE CONTACT FOA THIS LER (12)

NAME TELEPHONE NUMBER AREA CODE Thomas R. Bradish, Compliance Supervisor (ext. 6936) 60 93 2 5 300 COMPLETE ONE LINE fOR EACH COMPONENT FAILURE DESCRI ~ ED IN THIS REPORT (1$ )

CAUSE SYSTEM COMPONENT MANUFAC. EPORTASLE MANUFAC. EPOATASL TVAER TO NPADS CAUSE SYSTEM COMPONENT TVRER TO NPROS SUPPLEMENTAL REPORT EXPECTED IIll MONTH DAY YEAR EXPECTED SUBMISSION DATE (15)

YES Ill yer, C omPlere EXPECFED SVdktfSSIOIY DATE) NO ABSTRACT (Limit to (COO Ipecer, le., epproelmetely fr'fteen rindle tpece typewritten linn) 04l At 0001 on April 23, 1987 Palo Verde Unit 2 was in Mode 1 (POWER OPERATION) at 100 percent power when the time interval for sampling the concentration of hydrogen and oxygen in the gaseous radioactive waste system was exceeded. Grab Samples of the gaseous radioactive waste system were being taken daily as required by Technical Specification 3.3.3.9 ACTION 39 due to the inoperability of the inline hydrogen and oxygen analyzing system. Monitoring is conducted to detect the buildup of potentially explosive concentrations of hydrogen and oxygen in the system.

The root cause of the event was a cognitive personnel error by a chemistry technician (utility non-licensed) responsible for tracking performances of chemistry samples.

To prevent recurrence, a form is now in use to aid the chemistry technicians in determining what samples are required and when they need to be taken to Technical Specification ACTION requirements.

fulfill Although other similar events of missed chemistry samples have been reported, there have been no similar events where a surveillance test had been performed late due to a "tracking system entry error.

8705P7065y 87P5PO PDR ADOCK 05000529 S

PDR NAC eorm $ 44

NRC form 394A US. NUCLEAR REOULATORY COMMIS/ION

/9431 LICENSEE EVENT REPORT {LER) TEXT CONTINUATION APPAOVEO OMS NO 3150&IOt EXPIRES: 4/31/IN FACILI'TY NAME 111 DOCKET NUMEER 11l LER NUMSER IEI ~ AOE ISI YEAR SEQUENTIAL Il9 v IIlo rr NVM TR rrvM IA Palo Verde Unit TEXT //f moro tooco 2

/I rt/Rrtsd, vtt RtolCOnrt/P//IC forrrr JIRLA't/113) o so oo529 8 7 007 00. 02 OF 0 3 At 0001 on April 23, 1987, Palo Verde Unit 2 was in Mode 1 (POWER OPERATION) at 100 percent power when the time limit for sampling, the concentration of hydrogen and oxygen in the gaseous radioactive waste system (WE) was exceeded. This was discovered at approximately 0934 on April 23, 1987, by the oncoming shift chemistry technicians (utility non-licensed). Grab Samples of the gaseous radioactive waste system were being taken daily as required by Technical Specification 3.3.3.9 ACTION 39 due to the inoperability of the inline hydrogen and oxygen analyzing system.

Monitoring is conducted to detect the buildup of potentially explosive concentrations of hydrogen and oxygen in the system.

At 2300 on Apri1 21, 1987, grab sampling of the gaseous radwaste system was conducted. This was logged on the chemistry tracking system during the morning of April 22, 1987. The technician logged that the sample was taken on April 22, however, he should have logged that the sample was taken on the 21st. During the April 22 shifts, the chemistry technicians reviewed the tracking system and decided that a sample was not required since one had already been logged as taken.

The root cause of the event is considered to be a cognitive personnel error by the chemistry technician (utility non-licensed) responsible for logging the chemistry samples. This error is contrary to approved procedures. Procedures providing guidance in this area were reviewed and are considered adequate. A contributory factor to the error was the fact that times were not logged along with the dates of daily chemistry samples on the tracking system. Had the sample time been listed with the date, the oncoming shifts would have recognized that an error had been made on the tracking system. No unusual characteristics of the work location contributed to the error.

Two meetings were held as a result of this event with the PVNGS Plant Manager, members of his staff and Chemistry Supervision. The first meeting, involved discussions of the event and explored methods which could be utilized to ensure samples required by Technical Specifications would not be missed. As immediate corrective action implemented from this meeting, a "Current Chemistry Technical Specification Action Statement" form was developed. The form contains information as to what samples are required, and when the samples need to be taken in order to fulfill the appropriate Technical Specification ACTION requirements. The form also includes the time the analysis is completed.

A followup meeting was held to evaluate the effect of the immediate action. This meeting included the chemistry technician involved in this event and the Unit Lead Chemistry Technician. As a result of this meeting, it was decided to It permanently implement the form discussed above into the Chemistry program.

is expected that this action should prevent recurrence.

4RC IOIIM 3tto 19 43r

NRC Form 344A F343( UA. NUCLEAR REOULATORY COMMIEEION LICENSEE EVENT REPORT ILER) TEXT CONTINUATION AFFROVEO OMS NO 3(50WIOI EXFIRESI'3/31/N FACILITY NAME (1I DOCKET NUMEER (3(

LER NUMEER (4( ~ AOE (31 SEOVEHTIAL 5'4> AEVCION YEAR gg HUM 4II '(NUM EA TEXT Palo Verde Unit lllmo>> N>>oo *>>qcwed, ooo 2

aAN>>ool IYIIC%%dnn 33EA3 I (IT) 0 5 0 0 0 5 87 0 07 00. 03 OF 0' There were no structures, components, or systems, other than the hydrogen and oxygen analyzer, that were inoperable at the start of the event that contributed to the event. There were no operator actions that affected this event. There were no automatically or manually initiated safety system responses.

Samples taken before and after the event showed the concentrations of hydrogen and oxygen were within allowable limits. During the event, the gas stripper was not in operation so the addition of substantial amounts of hydrogen and oxygen to the gaseous radwaste system was unlikely. Therefore, this event had no impact on the health and safety of the public.

Although other similar events of missed chemistry samples have been reported, there have been no similar events where a surveillance test had been performed late due to a tracking system entry error.

Should other information pertinent to this event be discovered, a supplement to this report will be issued.

4RC ~ DAM 3444 14 83i

0 Arizona Nuclear Power Project P.o. BOX 52034 ~ PHOENIX. ARIZONA85072-2034

.192-00207-JGH/TRB/JHT May 20, 1987 U.S. Nuclear Regulatory Commission Document Control Desk Mashington, D.C. 20555

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Unit 2 Docket No STN 50-529

~

Licensee Event Report 87-007-00 File: 87-020-404

Dear Sirs:

Attached please find Licensee Event Report (LER) No. 87-007-00 prepared and submitted pursuant to 10 CFR 50.73. In accordance with 10 CFR 50.73(d), we are herewith forwarding a copy of the LER to the Regional Administrator of the Region V Office.

If you have any questions, please contact T. R. Bradish, Compliance Supervisor at (602) 932-5300 Ext. 6936.

Very tru y yours, J. G. Haynes Vice President Nuclear Production JGH/JHT/cld Attachment CCI O. M. DeMichele (all w/a)

E. E. Van Brunt, Jr.

J. B. Martin R. P. Zimmerman R. C. Sorensen E. A. Licitra A. C. Gehr INPO Records Center

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