ML17303A443

LER 87-014-00:on 870605,discovered That Auxiliary Sample Cart in Svc as Backup to Fuel Bldg Ventilation Radiation Monitor Turned Off & Inoperable.Caused by Personnel Error. Radiation Protection Technician terminated.W/870702 Ltr

ML17303A443
Person / Time
Site:	Palo Verde
Issue date:	07/02/1987
From:	Bradish T, Haynes J ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
192-00239-JGH-T, 192-239-JGH-T, LER-87-014-01, LER-87-14-1, NUDOCS 8707090386
Download: ML17303A443 (7)

Text

REGULAT<, INFORMATION DISTRIPUTIO SYSTEM (BIDS)

ACCESSION NHR:8707090386 DOC. DATE: 87/07/02 NOTARIZED: NO DOCKET FACIL: STN-50-529 Palo Verde Nuclear Stations Unit 2s AT i zona Publi 05000529 AUTH. NAME AUTHOR AFFILIATION BRADISHs T. R. Ari zona Nuc lear PoUjer ProJect ( f ormer lg Ar i zona Public Serv HAYNESs J. G. Arizona Nuclear Power ProJect (formerly Arizona Public Serv REC IP. NAME RECIPIENT AFFILIATION

SUBJECT:

LER 87-014-00: on 870605s discovered that auxiliary sample cart in svc as backup to fuel bldg ventilation radiation monitor tuTned off 5 inoperable. Caused bg personnel error.

Radiation protection technician terminated. W/870702 ltr.

DISTRIBUTION CODE: IE22D COPIES RECEIVED: LTR I ENCL Q SIZE:

TITLE: 50. 73 Licensee Event Report (LER)s Incident Rpts etc.

NOTES: Standardized plant. M. Daviss NRR: 1Cg. 05000529 REC IP IENT COP IES REC IP IENT COP IES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD5 LA 1 1 PD5 PD 1 LIC ITRAs E 1 1 DAVISs M 1 1 INTERNAL: ACR 8 MI C HELSON 1 1 ACRS MOELLER 2 2 AEOD/DOA 1 1 AEOD/DSP/ROAB 2 2 AEOD/DSP/TPAB 1 1 DEDRO 1 NRR/DEST/ADE 1 0 NRR/DEBT/ADS 0 NRR/DEST/CEB 1 1 NRR/DEST/ELB 1 1 NRR/DEST/ I CSB 1 1 NRR/DEST/MEB 1 1 NRR/DEST/MTB 1 NRR/DEST/PSB 1 NRR/DEST/RSB 1 NRR/DEST/SGB 1 NRR/DLPG/HFB 1 1 NRR/DLPG/GAB 1

'NRR/DOEA/EAB '1 1 NRR/DREP/RAB 1 NRR/DREP/RPB 2 2 /ILRB 1 1 NRR/PMAS/PTSB 1 E FI 02 1 RES DEPY QI 1 RES TELFORDs J 1 RES/DE/EIB 1 1 RQN5 FILE Oi 1 1 EXTERNAL: EGSQ GROHs M 5 5 H ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC HARRISs J 1 1 NSIC MAYSs G 1 1 NOTES:

TOTAL NUMBER OF COPIES REQUIRED: LTTR 46 ENCL 44

e NAC Form 3dd US. NUCLEAR REGULATORY COMMISSION IN)31 APPROVED OM 5 NO. 3)500104 LICENSEE EVENT REPORT {LER) EXPIAES: 5/31/SS FACILITY NAME (I) DOCKET NUMSER (2) PA E Palo Verde Unit 2

""'" Auxiliary Sampling Equipment for Effluent Releases Rendered 0 5 0 Inoperable 0 0 Due to OF Pers nnel Error MONTH EVENT DATE 15)

DAY YEAR YfAR:K>?

LfA NUMBER (dl S 4 0U4 rr 7 I A L v-'.I NVMSEII r?:N 4 ~

rrUMdfrl MONTH REPORT DATE (7)

DAY YEAR OTHER FACILITIES INVOLVED I~ )

FAC(LITY NAMES f DOCK T NUMSER(SI N A 0 5 0 0 0 0 5 30 87 7 ill(0 0 1 4 THIS REPORT IS SVSMITTEO PURSUANT T O THE 000 N A oi tnr torlorrinpl (11 0 5 0 0 0 OPERATING RE CUIR EMENTS OF 10 CF R Il. ICnrcc onr or morr MODE ( ~ I 20.402(O I 20.405(cl 50,73(r I (2) I iv) 73.71(o)

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LICENSEE CONTACT FOA THIS LER (12)

NAME TELFPHONE NUMSER AREA CODE Thomas R. Bradish Com liance Su ervisor Ext. 6936 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE OESCAISED IN THIS REPOR'7 (13I 602 393 -50 00 CAUSE SYSTEM COMPONENT MANUFAC EPORTASLf MANUFAC. EPORTASLE TURf R TO NPROS CAUSE SYSTEM COMPONENT TURER TO NPROS

@4%8(i SUPPLEMENTAL REPORT EXPECTED (14) MONTH OAY YEAR EXPECTED SVSMISSION DATE (I SI YES lit yr L comprrtv EXPECTED SVSMISSIOH OA PEI NO ASSTRACT (Limit to 1400 tprccL it., rpprovimrtrry Httrrn tinpir tprcr typrrvrrtrrn iron) (15)

On June 5, 1987 it was discovered that between 0610 and 0806 MST on May 31, 1987, with Palo Verde Unit 2 in Mode 1 (POWER OPERATION) operating at 100 percent power, the auxiliary sample cart, which was in service as a backup to the Fuel Building Ventilation Radiation Monitor (RU-145) had been turned off and rendered inoperable.

Subsequent investigation of the event identified a separate concern that on May 30-31, 1987 a Radiation Protection Technician (RPT) had not been correctly performing a sample flow verification to meet an ACTION Statement for the inoperable monitor RU-145. Both of these events are being reported as a violation of Technical Specification 3.3.3.8 since the appropriate ACTION Statements were not complied with.

The root cause for the inoperable sample cart was a personnel error by an l&C Technician who inadvertently repositioned the sample cart switch while working in the area to repair RU-145. The root cause of the improperly conducted sample flow verification was a conscious personnel error by the RPT.

As corrective action the sample cart was restored to operability at 0806 on May 31, 1987. The RPT has been terminated and a letter has been issued from the Arizona Nuclear Power Project (ANPP) Executive Vice President to all ANPP personnel to reiterate the company's position regarding the unacceptability of intentionally documenting erroneous information.

8707090386 870702 PDR ADQCI(v 0500052(7)

NRC Form 3dd S PDR

NRC Form 344A V.S. NUCLEAR REOULATORY COMMISSION 19 83 I LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPAOVEO OM8 NO 3IEOWI04 EXPIRES; 8/31/88 FACILITY NAME 111 DOCKET NUMSER 121 LER NUM4ER 141 PACE 131 YEAR Sf Qv4 NTIAL R 4 V IS IO Is NVM fR I/VM 4R Palo Verde Unit TEXT //F mort 2

sotct /I toIIttss. vw ot/'oooo/ H/SC Form 3//SA'sl 112) 0 5 0 0 0 5 2 8 7 00,02 QF 0 I

On June 5, 1987 it was identified that between 0610 and 0806 MST on May 31, 1987, with Palo Verde Unit 2 in Mode 1 (POWER OPERATION) operating at 100 percent power, the auxiliary sample cart, which was in service as a backup to the Fuel Building (ND) Ventilation System Low Range Radiation Monitor (RU-145)(IL)(RI), had been turned off and rendered inoperable.

RU-145 had been declared inoperable on May 20, 1987 and the appropriate Technical Specification (T.S.) ACTION Statements were entered. These actions included the utilization of an auxiliary sample cart to continuously sample for particulates and iodine in the Fuel Building Exhaust as required by T.S.

3.3.3.8, ACTION 40. On May 31, 1987 at approximately 0806, a Radiation Protection Technician (RPT)(contractor non-licensed) was conducting the sample flow verification required by T.S. 3.3.3.8, ACTION 36 when he discovered that the on/off switch for the auxiliary sample cart was in the off position and noted this fact in the Unit 2 Radiation Protection Logs. It was not until June 5, 1987 however, when the Senior RPT was conducting his review of the previous weeks'adiation Protection Logs in accordance with Procedure 75ST-9ZZ03, Radioactive Gaseous Effluents and RMS Surveillance, that the discovery of the mispositioned switch was brought to management's attention. In order to emphasize the need for RPTs to immediately report inoperable T.S. equipment or other potential concerns to the appropriate supervision, a memo that discusses this event and the need for tin/ely reporting will be issued to the RPTs for required reading.

An investigation was promptly initiated to determine the cause of the sample cart being turned off. As a result of the investigation it has been determined that the time of the event was between 0602 and 0641 on May 31, 1987. The root cause of the inoperable sample cart was concluded to be a personnel error by an Instrument and Control Technician (utility non-licensed) who inadvertently bumped the switch with his work manual while. wf,rking on RU-145 which is located on the same small elevated platform in the Fuel Building. Therefore, the sample cart was inoperable for a maximum time of approximately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />.

Upon discovery of the mispositioned switch at 0806 on May 31, 1987, the RPT immediately changed out the Particulate and Iodine sampling media and took the necessary actions to restore the sample cart to an operable status. The RPT also posted a note on the sample cart to warn others that a T.S. sample was in progress and not to disturb the cart. The radionuclide concentrations for the past three days were then calculated, using a conservative assumption, and the results were determined to be within the required limits. As corrective action to prevent recurrence, the grab sample carts (4 per each Unit) will have a placard installed on them which identifies the cart as a T.S. piece of equipment and to use caution when working in the area.

While conducting the investigation on the mispositioned sample cart switch, a separate concern was identified. It was discovered that a RPT (utility non-licensed) had not been correctly performing the required sample flow verification necessary to meet T.S. 3.3.3.8, ACTION 36. ACTION 36 requires that 4RC IORM 344A I9 43r

NRC form 9OCA U.S NUCLEAR REOULATORY COMMISSION I98TI LICENSEE EVENT REPORT (LERI TEXT CONTINUATION APPROVED OMS NO 9150 CIOO

'XPIRES; 9/91/88 FACILITY NAME III OOCKET NUMSER I?I LER NUMEER IE) ~ AOE ITI Sr'm SEQI/ENT/AL +O rrEVrorQrr rrUM Tll "~~ MUMPTA P 1 V 0 5 0 0 0 OF 5 0 1 4 0 0 0 3 TEXT /// moro orroco

• oorrrworL rroo ~ /Oooro/H/IC Forrrr RFEAVI lltl every four hours the sample flow to the cart b - verified consistent with an estimated flow. To accomplish this, it is necessary to enter the Fuel Building and ascend the stairs to the sample cart and read a flow meter. Based on a review of the Automated Control Access Device (ACAD) transaction printout it was determined that at approximately 0030 on May 30, 1987 and 0410 on May 31, 1987, the RPT had not entered the Fuel Building, as he had documented, to conduct the sample flow verification required by T.S. Failure to conduct the sample flow verification renders the sample cart inoperable.

The root cause of the improperly conducted sample flow verification was a conscious personnel error by an RPT who did not conduct the verification and then inappropriately documented it as complete in the Radiation Protection Logs.

As corrective action to prevent recurrence, the RPT has been terminated. In addition, a letter has been issued from the Arizona Nuclear Power Project (ANPP)

Executive Vice President to all ANPP personnel to briefly discuss this event and to reiterate the company's position regarding the unacceptability and the potential consequences of intentionally documenting erroneous information.

An independent evaluation has been conducted to determine if additional corrective actions are necessary. As a result, additional corrective actions including the development of a video tape message from the Executive Vice President and the initiation of random checks of various departmental activities against the ACAD transaction printouts are currently being considered for implementation.

The sample cart is. utilized as a backup to RU-145 which is installed to monitor releases through the Fuel Building Exhaust which results from a fuel handling accident or a Loss of Coolant Accident (LOCA). At this time there is no spent fuel stored on site and in the case of a LOCA, an RPT would have to enter the Fuel Building and go to the sample cart to obtain a grab sample for analysis.

It would then be obvious that the cart was turned off and could be easily it restored to obtain the grab sample. Therefore, this event did not adveresly affect the safe operation of the plant or the health and safety of the public.

The failure to properly conduct the sample flow verifications did not present a safety concern as evidenced by the fact that the sample cart was shown to always have been operable based on the subsequent sample flow verifications which were correctly conducted following the two missed flow verifications. The sample cart continued to perform its intended function although it was not verified at the correct time intervals. Therefore, this event did not adversely affect the safe operation of the plant or the health and safety of the public.

There were no structures, components, or systems that were inoperable at the start of the events, other than those previously described, that contributed to the events. There were no unusual characteristics of the work location which contributed to the events. There were no automatic or manually initiated safety system responses. No operator actions were required as a result of the events.

There are no specific procedures that were violated in either event previously described. There are no procedural controls curre>Itly in place that address v/IC r OrlM TOOA I9 ET/

NRC form 344A U.S. NUCLEAR REGULATORY COMMISSION IQ 83)

LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVED OMQ NO, 3(SO~I()4 EXPIRES: 8131I88 FACILITY NAME (Il DOCKET NUMQER (1)

LER NUMQER (4) PAGE LT)

YEAR SEGVSNTIAL sr 4 v rs Io N NVM SSI N V>>44 A Palo Verde Unit TEXT (If rrroro u>>so i( orrrirosE vso 2

Fdcf 'on>>(HRC Forrrr 388l'4) ((3) 0 5 0 0 0 5 2 8 7 014 00 04 QF 0

either issue and under the circumstances described above, ANPP believes that there are no procedural controls that would have prevented the occurrences.

An additional investigation is being conducted to determine other T.S. radiation monitors which the RPT may have not conducted the if there were any appropriate actions for. Should this investigation result in additional similar findings, a supplement to this report will be issued.

There have been no previous similar events regarding a sample cart which was inadvertently turned off however, a similar event involving an RPT who intentionally documented erroneous information was previously reported in Unit 1 LER 86-058-00.

The corrective actions taken in response to the Unit 1 event were considered appropriate for the specific problem identified. The corrective actions taken to prevent recurrence of the Unit 1 problem were also considered appropriate however, they could not be expected to prevent somone from intentionally documenting erroneous information. Additionally, as a result of the previous Unit 1 event, an evaluation was conducted by the ANPP Personnel Department to determine if human factors, such as morale, working conditions, etc., could be a contributory cause to the event. No concerns of this type were identified.

NsrC s Orrv 344k IQ 43>

Arizona Nuclear Power Project P.O. SOX 52034 ~ PHOENIX, ARIZONA 85072-2034 192-00239-JGH/TRB/TJB July 2, 1987 Document Control Desk U.S. Nuclear Regulatory Commission Washington, D.C. 20555

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Unit 2 Docket No. 50-529 Licensee Event Report 2-87-014 File: 87-020-404

Dear Sirs:

Attached please find Licensee Event Report (LER) No. 2-87-014 prepared and submitted pursuant to 10CFR 50.73. In accordance with 10CFR 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) 393-5000, Ext. 6936.

Very truly yours,

.g g.

G. Hayne Vice President Nuclear Production JGH/TJB/cld Attachment cc: 0. M. DeMichele (all w/a)

E. E. Van Brunt, Jr.

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

~gP I /i

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