ML17303B004

LER 87-021-01:on 871202,post-accident Sampling Sys Declared Inoperable.Caused by Personnel Error.Appropriate Functional & Surveillance Tests Completed & Sys Decalred Operable.W/ 880407 Ltr

ML17303B004
Person / Time
Site:	Palo Verde
Issue date:	04/07/1988
From:	Haynes J, Shriver T ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
LER-87-021, LER-87-21, NUDOCS 8804130036
Download: ML17303B004 (7)

Text

l giQO@~MTEO DIBUTION DEMONSTJQITION C4 REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:8804130036 DOC.DATE: 88/04/07 NOTARIZED: NO DOCKET FACIL:STN-50-529 Palo Verde Nuclear Station, Unit 2, Arizona Publi 05000529 AUTH. NAME AUTHOR AFFILIATION SHRIVER,T.D. Arizona Nuclear Power Project (formerly Arizona Public Serv HAYNES,J.G. Arizona Nuclear Power Prospect (formerly Arizona Public Serv RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 87-021-01:on 871202,post-accident sampling sys declared inoperable.

W/8 ltr.

DISTRIBUTION CODE: IE22D COPIES RECEIVED:LTR L TITLE: 50.73 Licensee Event Report (LER),

ENCL 2 SIZE:

Incident Rpt, etc.

NOTES:Standardized plant. 05000529 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME 'TTR ENCL ID CODE/NAME LTTR ENCL A PD5 LA 1 1 PD5 PD 1 1 LICITRA,E 1 1 DAVIS,M 1 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 AEOD/DOA 1 1 AEOD/DSP/NAS 1 1 AEOD/DSP/ROAB 2 2 AEOD/DS P/TPAB 1 1 ARM/DCTS/DAB 1 1 DEDRO 1 1 NRR/DEST/ADS 7E 1 0 NRR/DEST/CEB 8H 1 1 NRR/DEST/ESB 8D 1 1 NRR/DEST/ICSB 7 1 1 NRR/DEST/MEB 9H 1 1 NRR/DEST/MTB 9H 1 1 NRR/DEST/PSB 8D 1 1 NRR/DEST/RSB 8E 1 1 NRR/DEST/SGB 8D 1 1 NRR/DLPQ/HFB 10 1 1 NRR/DLPQ/QAB 10 1 1 NRR/DOEA/EAB 11 1 1 NRR/DREP/RAB 10 1 1 NRR/DREP/RPB 10 2 2 NRB/J3 - SIB 9A 1 1 NRR/PMAS/ILRB12 1 1

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RES/DE/EIB 02 1 1

1 1

RES TELFORD,J RES/DRPS DIR 1

1 1

1 RGN5 FILE 01 1 1 EXTERNAL: EG&G GROH,M 4 4 FORD BLDG HOY,A 1 1 H ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC HARRIS,J 1 1 NSIC MAYS,G 1 1 NOTES: 1 1 A

2 TOTAL NUMBER OF COPIES REQUIRED: LTTR 47 ENCL 46

NRC Form 3SS US. NUCLEAR REOULATORY COMMISSION r (903)

APPRDYED DMB No. 3(600(oc LICENSEE EVENT REPORT fLER) EXPIRES: Sl31lSS FACILITY NAME (II DOCKET NUMBER (2) PA Palo Verde Unit 2 o s o o o 52 91oF05 TITLE (CI PASS Incorrectl Declared Operable EVENT DATE ISI LER NUMBER IS) REPORT DATE I Tl OTHER FACILITIES INVOLVED (S)

MONTH OAY YEAR YEAR SNOUNHTIAL Pol RSVtclQrt MONTH OAY YEAR FACILITYNAMES DOCKET HUMBERISI HVMSSR:CCS HUMOSII N/A 0 5 0 0 0 1 202 878 7 0210104 0 7 8 8 N/A THIS REPORT IS SUBMITTED PURSUANT 7 0 THE REDUIREMENTB of 10 cFR (): (corer one or morr ol tnr fodowlnpl (11 0 5 0 0 0 OPERATINO MODE (9) 20A02(bl 20AOS(cl 50.73(c)(2)(lr) 73.7((II I POWER 20AOS te) (I III) SO.SS(c) (1) 00.73(e)(2) Nl 73.71(cl LEYEL 1 0 0 20AOS(e)(1)IN) S0.30(c)(2) S0.73(e) 12) leN) OTHER (dpeclty In Abttrrct below entt ln Tert, HRC Form 20AOS(el(1)(NII 00.73(e I 12) I II 00.73(e l(2)(riN I(A) JPEAI

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$ 20AOS(el(1((lrl 00.73(r ) (2) IN) 00.73(r ) (2) (r(NI (0 I Special Report 20AOS(e)11)(r) 50.73(e)(2)(INI 00.73(r I (2 I (el 2-SR-87-030 LICENSEE CONTACT fOR THIS LKR (12)

NAME TELEPHONE NUMBER AREA CODE Timothy D. Shriver, Compliance Manager 6 02 39 3- 25 21 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE OESCRISKD IN THIS REPORT (LS)

CAUSE SYSTEM COMPONENT MANUFAC. MANUFAC. EPORTABLE TURER SYSTKM COMPONENT TURER TO NPRDS !SL%YLI I""IIIII(51I AÃkWII I!%2I)$k SUPPLEMENTAL REPORT KXPKCTEO (ICI MONTH DAY YEAR EXPECTED SUBMISSION DATE IISI YES flfyec, complrtr EXPECTED SUdltlSSIOH OATEI X HO ABKTRAcT (Limit to le00 tpecet, l A, epptor pnetely ftltern tlnple tpece typcrwittrn b'net) (I ~ I This is a supplement to LER 2-87-021-00 At approximately 1440 HST on December 2, 1987 the Post-Accident Sampling System (PASS)(IP) was declared inoperable following discovery of an improper valve lineup. The lineup was performed on November 7, 1987 to permit installation of two PASS check valves (IP)(V). Work was suspended and the PASS declared operable at approximately 1220 HST on November 9, 1987. Based on subsequent investigation, the PASS was determined to have been inoperable since approximately 0405 flST, November 7, 1987, and to have exceeded the 7 day limit for ipoperability per Technical Specification (T.S.) 3.3.3.1 at 0405 HST on November 14, 1987. The Prep'lanned Alternate Sampling Program (PASP) was initiated at 1420 HST on December 4, 1987, therefore Palo Verde Unit 2 operated for approximately 20 days in a condition contrary to T.S. 3.3.3.1.

As immediate corrective action the PASS was restored, tested for operabi.lity, and declared operable at 1900 HST on December 6, 1987.

The root cause of this event was determined to be personnel error contrary to approved procedures. This event was subsequently investigated, and the corrective actions required to prevent recurrence are provided in this report supplement This LER also provides a special report in accordance with T.S. 3.3.3.1 ACTION 28(2) and 6.9.2. No similar events have been identified.

~@~Z 8804130036 880407 PDR ADOCK 05000529 8 DCD

NRC form 38SA U.S. NUCLEAR REOULATORY COMMISSION 1943)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMS NO 3150&)04 EXPIRES: 8/31/88 PACILITY NAME )11 OOCKET NUMSER (3) LER NUMSER )8) PACE IS) 8)%' f QVfNT/AI.

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/)4 V/SK)/I N V M 4 4 /I Palo Verde Unit 2 o s o o o 5 2 9 8 8 0 2 1 Ol 02 OF 05 TEXT //f mom a>>fo /4 mfooaL uoo ~HhC fooo 3$ )ASI OT)

This is a supplement to LER 2-87-021-00.

This LER supplement also provides a special report, submitted in accordance with Technical Specification (T;S.) 3;3.3.1 ACTION 28(2) and 6.9.2.

At approximately 1440 NST on December 2, 1987, Palo 'Verde Unit 2 was in I1ode 1 (POWER OPERATION) at 100 percent power when the Post-Accident Sampling System (PASS)(IP) was declared inoperable due to the discovery of an improper valve (IP)(V) lineup which could have prevented the collection of required samples.

This condition was identified by chemistry personnel (utility, non-licensed) on December 1, 1987, during the conduct of the PASS monthly functional surveillance, test. The valve lineup had originally been performed under an approved clearance on November 7, 1987 to permit the installation of two PASS check valves (IP)(V). The work was suspended prior to completion pending the receipt of required parts. The PASS was declared operable at approximately 1220 HST on November 9, 1987. It was later determined that the affected valves'had not been restored and were left in the closed position. Some of the affected valves are located in the PASS pit of the 70 ft. elevation of the Auxiliary Building (NF) and would have been inaccessible under postulated accident conditions. Based on this information the PASS was determined to have been inoperable since approximately 0405 HST on November 7, 1987.

Technical Specification (T.S.) 3.3.3.1 ACTION 28(1) requires that the PASS be restored to operable status within 7 days or that the Preplanned Alternate Sampling Program (PASP) be initiated. The 7 day limit for inoperability was exceeded at approximately 0405 HST on'Nover)aber 14, 1987. The PASP was initiated at 1420 t1ST on December 4, 1987, therefore Palo Verde Unit 2 operated for approximately 20 days in a condition contrary to T.S. 3.3.3.1.

At approximately 1030 t1ST on December 1, 1987, chemistry personnel (utility, non-licensed) notified Control Room personnel (utility licensed) that procedure 74ST-2SS04, "PASS Functional Test," would be performed. During the performance of the test the required sample flow could not be established and the chemistry technician (utility, non-licensed) commenced a system valve lineup verification. The technician found that the discharge valve for the backup nitrogen supply tanks in the gas cylinder storage area of the chemistry hot lab was "red-tagged" shut. The Control Room personnel (utility, licensed) were informed, and they determined that the tag was associated with a clearance that had been cancelled on November 9, 1987.

After notifying Control Room personnel, the chemistry technician removed the tag and opened the valve. The surveillance test was again commenced, however, the required sample flow still could not be established. The technician then determined that the other valves affected by the clearance, although the Ured tags" had been removed, had not been properly restored following the work completed on November 9, 1987.

The chemistry technician performed a valve lineup in accordance with procedure 740P-2SSOl, "Operation of the Post-Accident Sampling System," infort;)ed 4AC 1 0AM 3444 19 83>

NRC Form 388A

/983) ~ U.8. NUCLEAR REOULA'TORY COMMISSION LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVEO OMS NO. 3150-0104 EXPIRES: 8/31/88 COCKET NUMEER l31 LER NUMEER (8l SSQUSNTIAL ggI REVISION YEAR gg NUMSSR NUMOSR Pal'o Verde TEXT ///moro spo>> (8 Unit 2 rosond. o>> ///o'oro/A(/TC Fo/IR 3/PSA3/ I ill o s o o o 5 2 9 8 8 0 2 1 0 1. 03oF 05 chemistry management (utility, non-licensed) and resumed the surveillance testing. The chemistry manager (utility, non-licensed) determined that the event described above had rendered the PASS inoperable as of 0405 HST on November 7, 1987, when the system was tagged out for the check valve installation, and notified the Control Room. Upon notification, Control Room personnel (utility, licensed) documented the PASS inoperability at approximately 1440 HST, December 2, 1987.

Subsequent investigation revealed that the clearance had been issued to permit the installation of two check valves in accordance with an approved work document. This work was performed utilizing "Work to Commence" Field Change Requests (FCRs) as work order attachments. One of the check valves (2J-SSN-CV-073) was installed, but the installation of the second check valve was delayed for parts. It was determined that PASS could be operated without the second check valve installed, therefore, the decision was made to suspend the work and return the PASS to an operable status until the parts were available and the work could be completed.

Prior to declaring the PASS operable, the assistant shift supervisor (utility, licensed) consulted with the system engineer (utility, non-licensed) regarding necessary retest requirements for the check valve that was installed. The work doc'ument had specified that an operational check be p'erformed upon installation of both check valves, however, the systems engineer determined that no retest was required for the check valve that was installed since it was located on an open ended drain line. There is no specific procedural guidance provided that requires particular retest requirements for each maintenance/modification activity. The guidance provided is considered adequate, however, when utilized by a trained and knowledgeable engineer.

Although the engineer made an error in judgement when he did not specify the appropriate retest requirements for the installed check valve, no procedural controls were violated and it is not certain that a post-modification retest of the installed valve would have identified the improper valve lineup. Based on the system engineer s determination, the assistant shift supervisor did not require a retest.

The assistant shift supervisor directed the chemistry personnel to remove the issued tags for the clearance, but did not direct a restoration of the affected equipment.

The chemistry technician (utility, non-licensed) completed removing the tags at approximately 0945 HST on November 9, 1987, and returned the tag assignment sheet and the pulled tags to the assistant shift supervisor. As previously discussed, it was later found that one of the tags had not been removed. This is considered a cognitive personnel error by the responsible chemistry technician (utility, non-licensed) which was contrary to an approved procedure. The assistant shift supervisor then cancelled the clearance and declared the PASS operable at approximately 1220 HST on November 9, 1987.

4RC IORM SSSA I9 83(

NRC Folm 344A 19.83 I V.S. NUCLEAR REOVLATORY COMMISSION LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVEO OMS NO 3150 0104 EXPIRES: 8 131/88 FACILITY NAME III OOCKET NVMSER (31 LER NVMSER NI SEOVENTIAL ieger REVISION NUM 4 II '-~F NUMEER Palo Verde Unit 2 o s o o o 5 29 8'7 0 2 1 0 1 04 oF 0 5 TEXT IIF mom 40444 4 IFEII9eC v44 NAWiMWITALIC FEml BASSA'El IITI Approved administrative controls require that the shift/assistant shift supervisor direct and verify the proper restoration of a systerII prior to removing a clearance and declaring the system operable. In this event these procedural controls were not followed, therefore, this cognitive personnel error by the assistant shift supervisor (utility, licensed) was contrary to an approved procedure and contributed to the event. This determination is based on the fact that, if the procedural controls had been implemented, the error committed by the chemistry technician and the lack of proper system restoration would have been identified prior to returning the system to an operable status.

As corrective action, Control Room personnel directed that the PASP be initiated and a work order amendment implemented to functionally test the installed check valve. The appropriate functional and surveillance tests were completed, and at 1900 NST on December 6, 1987, the PASS was declared operable. The total elapsed time from the discovery of the event to the restoration of the PASS to an operable status was approximately 4 days, 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> and 20 minutes. The overall duration of this event was approximately 22 days.

As interim corrective action to prevent recurrence the Unit 2 Plant IIanager directed that, in addition to Operations, all Unit 2 departments having jurisdiction over plant equipment shall comply with the additional guidelines imposed by Operation's Department Guideline (ODG) 17, "System Status Control." As a prudent action it has been decided to implement this corrective action in Units 1 and 3.

As discussed above, the root cause of this event is considered to be cognitive personnel errors contrary to approved procedures by both control room personnel and the chemistry technician, potentially contributed to by the judgemental error of the system engineer. Initial evaluation identified that the existing procedural controls were adequate. Cognitive personnel errors described herein are primarily the result of mental lapses and are not normal'ly correctable with revised procedures. However, as a prudent measure, ANPP conducted a special investigation and the following additional corrective actions will be implemented:

Unit Chemistry personnel will be required to review the special investigation report supplement as additional training to ensure that the appropriate attention to detail is maintained.

NRC EORM 344A I9 831

NRC form 344A U.S. NUCLEAR REOULATORY COMMISSION I9 83 I LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMS NO. 3150 0104 EXPIRES: 8/31/88 FACILITY NAME III OOCKET NUMSER Ill LER NUMSER IS) PACE LTI

~>>m SSOUSNT/AL +81 rlsvrsroN NUMSSA NUM44R Palo Verde Unit TEXT //P /rroro I/roco II /4//rkorL ooo An

~ 2 H/IC forrrr JREA9/ IITI os 0 0 o 52 98 administrative control procedure for statusing systems, similar to 7 0 2 1 0 1 OF 0 5 ODG-17, will be developed for use by all departments within Units I, 2, and 3.

Interface agreements will be coordinated and made part of the controls contained in the station manual.

Procedural controls for the administration of Technical Specification Component Condition Reports (TSCCR's) will be revised to include verification steps to be signed by the department which has responsibility for system restoration and declaration of operabi'lity.

Procedural controls will be revised to provide more specific direction concerning the minimum requirements to be utilized for declaring systems operable following work completion.

Future plant changes or site modifications will contain requirements for ensuring that an in-service checklist is completed for partially completed modifications prior to returning a system to service.

There were no structures, systems or components inoperable at the start of the event, other than those described above, that contributed to the event. There were no automatically or manually initiated safety system responses. There were no unusual characteristics of the work location that contributed to the event. There were no safety implications associated with this event because of the ability to implement the Preplanned Alternate Sampling Program.

No similar events involving failure to restore the PASS to operability following the completion of work activities have been reported.

~ IIIC ~ Orrm 344A I9 83>

Arizona Nuclear Power Project P.O. BOX 52034 ~ PHOENIX, ARIZONA85072-2034 192-00360-JGH/TDS/DAJ April 7, 1988 NRC Document Control Desk U. S. Nuclear Regulatory Commission Washington, D.C. 20555

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Unit 2 Docket No. STN 50-529 (License NPF-51)

Licensee Event Report 2-87-021-01 File: 88-020-404 Attached please find Supplement No. 1 to Licensee Event Report (LER) No.

2-87-021-00 prepared and submitted pursuant to the requirements of 10CFR 50.73(d). We are herewith forwarding a copy of this report to the Regional Administrator of the Region V Office.

If you have any questions, please contact T. D. Shriver, Compliance tlanager at (602) 393-2521.

Very truly yours,

. G. Haynes Qc.c) ~

Vice President Nuclear Production JGH/TDS/KCP/kj Attachment CC: 0. H. DeMichele (all w/a)

E. E. Van Brunt, Jr.

J. B. Hartin T. J. Polich R. C. Sorensen E. A. Licitra A. C. Gehr INPO Records Center