ML17303B060

LER 88-006-00:on 880320,surveillance Interval for Incore Detector Sys Exceeded.Caused by Cognitive Personnel Error & Inadequate Programmatic Controls.Individual Involved Will Be Counseled &/Or Disciplined & Controls reviewed.W/880419 Ltr

ML17303B060
Person / Time
Site:	Palo Verde
Issue date:	04/19/1988
From:	Haynes J, Shriver T ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
192-00368-JGH-T, 192-368-JGH-T, LER-88-006, LER-88-6, NUDOCS 8804260007
Download: ML17303B060 (13)

Text

'CCELERATED DIFJMBUTION DEMONSTR110N SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR-8804260007 DOC-DATE- 88/04/19 NOTARIZED- NO DOCKET FACIL:STN-50-528 Palo Verde Nuclear Station, Unit 1, Arizona Publi 05000528 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'erv RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 88-006-00:on 880419,surveillance interval exceeded for incore detector sys.

W/8 ltr.

DISTRIBUTION CODE: IE22D COPIES RECEIVED:LTR ENCL SIZE:

TITLE: 50.73 Licensee Event Report (LER), Incident Rpt, etc.

NOTES:Standardized plant. 05000528 S RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD5 LA 1 1 PD5 PD . 1 1 LZCITRA,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/DSP/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 N -DR.IN B 9A 1 1 NRR/PMAS/ILRB12 1 1 02 1 1 RES TELFORD,J 1 1 RES/DE/EIB 1 1 RES/DRPS DIR ~

1 1 RGN5 FILE 01 1 1 EXTERNAL EG &G GROH g M 4 FORD BLDG HOY,A 1 1 R H ST LOBBY NARD 1 1 LPDR 1 1 NRC PQR 1 1 NSIC HARRIS,J 1 3.

NSIC MAYS,G 1 1 D

NOTES 1 1 S

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TOTAL NUMBER OF COPIES REQUIRED- LTTR 47 ENCL 46

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NRC Form 355 U.S, NUCLEAR REGULATORY COMMISSION IMI3)

APPROVED OM 5 NO. 31500104 LICENSEE EVENT REPORT (LER) EXPIRES: SI31/BB FACILITY NAME (I) DOCKET NUMBER (2) PA 5 TITLE ( ~ )

Palo Verde Unit 1 o s o o o 52 8ioF05 Surveillance Interval Exceeded For Incore Detector System EVENT DATE 15) LER NUMBER IS) REPORT DATE (7) OTHER FACILITIES INVOLefED (SI MONTH DAY YEAR YEAR e+ SEOUENTIAL Sip norton)N MONTH DAY YEAR FACILITYNAMES DOCKE'7 NUMBER(3)

'sinF NUMBER:Bn NUMBER N/A 0 5 0 0 0 0 32088 88 006 00041 98 8 N/A o 5 o o o THIS REPORT IS SUBMITTED PURSUANT T 0 THE REOUIREMENTS OF 10 CFR (I: ICn<<O one or more ol tne folforrfnff (11 OPERATING MODE IB) 20.402(O) 20.405(c) 50.73(e)(2)IIrl 73.71(O)

POWER 20.405(e) (I IIII 5035(c) (I I 50.73(e I (2) (r) 7371(c)

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] 0 0 20.405(e) II I(Q) 50.35(c) (2) 50.73(e) (2) (rB) OTHER (Specify ln Apt(rect trerorrend In Text, HIIC Form 20.405M) (I IIrS) 50.73(el(2) IB 50.73(e l(2)(rBI I(AI JSSAJ 20.4N(e I ( I I (tel 50.734) (2)(5) 50.73 Ie) 12) (r)B I( 5) 20.405 (e) (I ) (r) 50.73(el(2) (BO 50,73(e) (2)(r I M%4Yp<'AME LICENSEE CONTACT FOR THIS LER (12)

TELEPHONE NUMBER AREA CODE Timothy D. Shrivero Compliance Manager 602 39 3 252 1 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE OESCRI ~ EO IN THIS REPORT (13)

MANUFAC EPQRTAB LE MANUSAC. r ORT ry CAUSE SYSTEM COMPONENT TURER TO NPRDS QQ~g+5> CAUSE SYSTEM COMPONENT TURER Qgjgg!. Q@:

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SUPPLEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR EXPECTED SUBMISSION YES illyn, complete EXPECTED SUdotISSIDIf DATE)

DATE (I BI 05 20 88 ABSTRACT l(,lmlt to tc00 s>>cet, I o., opproeimetely fifteen tlnfle.tpece typerrritten linnl (15)

On March 21, 1988, Palo Verde Unit 1 was in Mode 1 (POWER OPERATION) at 100 percent power when engineering personnel (utility, non-licensed) determined that the allowable surveillance test interval had been exceeded for the incore detector system (IG). This resulted in the incore detector system and the Core Operating Limit Supervisory System (COLSS) (ID) becoming administratively inoperable.

The root cause of the event was a cognitive personnel error by engineering personnel (utility, non-licensed) responsible for assigning the performance of the surveillance test. To prevent recurrence, the individual will receive appropriate counseling and/or disciplinary action.

A preliminary evaluation has determined that a contributory cause was inadequate programmatic controls to ensure surveillance tests are conducted within the specified intervals.

A supplement to this LER will be issued describing the results of the review of the programmatic controls and the necessary corrective actions to prevent recurrence.

8804260007 S80419 PDR ADOCK 05000523 S . . DCD NRC Form 345

NRC form SSSA U.S. NUCLEAR REGULATORY COMMISSION (949 I LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVED OMS NO 4150&104 EXPIRES'. 4/SU44 FACILITY NAME 111 DOCKET NUMEER ISI LER NUMSEII Idl ~ AOE ISI YEAII grRr Sdovsrrfr*L '~'~

~dr~ Advrsrorr NVM rl rrVM do Palo Verde Unit 1 o 5 o o o 52 888 00 6 00,02 OF 0 5 TEXT Nmoro ooooo N>>drriorE rrw ofooo'ooo HlIC form IIYJIITI I. DESCRIPTION OF WHAT OCCURRED A. Initial Conditions:

On Harch 21, 1988, Palo Verde Unit 1 was in Hode 1 (POWER OPERATION)

(at normal operating pressures and temperatures) following the first refueling outage.

B. Reportable Event Description (Including Dates and Appropriate Times of Ha)or Occurrences)

Event Classification: Condition Contrary to the Plants Technical Specifications On Harch 21, 1988, engineering personnel (utility, non-licensed) determined that the allowable surveillance test interval had been exceeded for the incore detector system. Specification 4.3.3.2.a requires a CHANNEL CHECK of the incore detector system at least once per seven days. The incore detector system (IG) is required to be OPERABLE when the Core Operating Limit Supervisory System (COLSS)(ID) is utilized for monitoring the AZIHUTHAL POWER TILT, Radial Peaking Factors, Local Power Density, and Departure from Nucleate Boiling (DNB) Hargin.

On Harch ll, 1988 at approximately 1150 HST, a surveillance test of the incore detector system was completed. The next surveillance test was due on Harch 20, 1988 at approximately 0550 HST (the interval includes the 25 percent tolerance allowed by Technical Specification 4.0.2). Subsequent to the discovery that the surveillance interval had been exceeded, the surveillance test was satisfactorily performed on Harch 21, 1988 at approximately 1032 HST.

On Harch 21, 1988, after the responsible engineer had informed the Shift Supervisor (utility, licensed) that the incore detector system and COLSS were inoperable,. the surveillance test for COLSS out of service was initiated. To comply with the Limiting Condition for Operation T.S. 3.2.1, 3.2.2, 3.2.3 and 3.2.4, the reactor power was reduced to approximately 91 percent and appropriate surveillance tests conducted.

C. Status of structures, systems, or components that were inoperable at the start of the event which contributed to the event:

Other than described above, no structures, systems, or components were inoperable at the start of the event that contributed to the event.

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U' NRC Form ESSA I98SI U.S. NUCLEAR REOULATORY COMMISSION LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVEO OMS NO. SI$ 0&I04 EXPIRES: 9131/SS FACILITY NAME (l) OOCKET NUMSER Ql LER NUMSER LEI ~ ACE (SI AS V IS IQ Il YEAR gSi SEQVENTIAL NVM SA IIVM S A Pal 0 Verde Uni t 1 o s o o o 52 888 006 0 003OFO 5 TEXT Illmore soece il reeeired. o>> +dice'orMI HRC foml ~'llII TI D. Cause of each component or system failure:

Not applicable - no component or system failures were involved; however, the cause of the administrative inoperability of the incore detector system is considered to be a cognitive personnel error.

Preliminary evaluation has determined that inadequate programmatic controls contributed to the event.

E. Failure mode, mechanism, and effect of each failed components:

Not applicable - no failures were involved.

F. For failures of components with multiple functions, list of systems or secondary functions that were also affected:

Not applicable - no failures were involved.

G. For failure that rendered a train of a safety system inoperable, estimated elapsed time from the discovery of the failure until the train was returned to service:

Not applicable. No safety system failures were involved; however, the surveillance test interval was exceeded on March 20, 1988 at approximately 0550 HST. On March 21,'988 at approximately 0715 HST, the responsible engineer determined the surveillance test interval was exceeded and notified the Shift Supervisor (utility, licensed).

The surveillance test was satisfactorily performed on March 21, 1988 at approximately 1032 HST. The incore detector system and COLSS were administratively inoperable for approximately 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> and 17 minutes.

H. Method of discovery of each component or system failure or procedural error:

Not applicable - no failures or procedural inadequacies were involved.

Cause of Event:

The cause of the event was identified as a cognitive personnel error. The responsible engineering personnel did not ensure that the surveillance test was conducted within the allowable time interval.

The error was contrary to approved procedural controls. These procedural controls provide sufficient guidance in this area. There were no unusual characteristics of the work location or other personnel errors that contributed to the event.

Although the procedural controls were considered adequate, the lack of a specific proceduralized program to track the required MAC lOAM SSSO (9 SSI

NRC Form SSSA US. NUCI.EAR REOULATORY COMMISSION 1943)

UQEN$ FE EVENT REPORT tLER) TEXT CONTINUATION EXFIRES. EI31 Ila FACILITY NAME III OOCKET NUMEER ISI, LER NUMEER Iff FAOE ISI YEAR lg SEOVSNTIAL NVM rl S

VNION NVM Pal 0 Verde Uni TEXT nt mero saeoe N reerkaE Iree ~t 1 AIRC lrerm SISEA'll 113) o s o o o 5 2 8 8 surveillance tests is considered to be a zpntributing cause. A 80 0 6 00, 04ov 0 5 supplement to the report will be issued..descrjbing;%he results. of the review of the programmatic controls.

J. Safety System Response No safety system responses were actuated'.zone were:expected.

K. Failed Component Information Not applicable - no failures were involved.

II. ASSESSHENT OF THE SAFETY CONSEQUENCES'ND -IHP17CATXQNS DF THIS EVENT:

No safety consequences or implications'resulted Vrom this event. The incore detector system and COLSS were administratively inoperable when the surveillance test was not completed by. ihe end, of the surveillance test interval. A review of the surveillance test results demonstrates that the incore detector system met applicable test criteria prior to and after the period of administrative inoperability. This was substantiated by data taken on Harch 16, 1988 which wassanalyzed and demonstrated that the incore detector system and COLSS were functioning properly.

I I I. CORRECTIVE ACTIONS:

A. Immediate:

Technical Specification Limiting Condition-for .Operation'ACTION 3.3.3.2.2, 3.2. 1, 3.2.2, 3.2.3 and 3.2.4~re,entered upon event discovery and preparations to reduce power were commenced. Reactor power was decreased to approximately 9N ~conform with-%he Limiting Conditions for Operation -for DNB margin Ath,COLSS out of:.service.

The surveillance test for COLSS out of, service was also initiated.

The applicable surveillance test was satisfactorily. completed.

Bs ACTION TO PREVENT RECURRENCE The responsible individual will receive-appropriate',counseling and/or disciplinary action. A supplement to':this LER will be issued describing the review of the programmatic:controls=and any additional corrective action necessary to prevent,.recurrence.

IV. PREVIOUS SIHILAR EVENTS Previous similar events have been reported0n. Licensee Event Reports85-015, 85-034,86-012 and 86-016 for Unii. 1:and 86-029,';.B6-035 and 87-007 for Unit 2, which involved failing .to iniiiate.routine]y:scheduled 4IIC IOIIM SSSA IS SSI

NRC 19431 foiw 3ddA US. NUCLEAR REOULATORY COMMISSION LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMS NO. 3150WI04 EXPIRES: d/31/Nl fACILITYNAME Ill POCKET NUMEER 131 LER NUMEER ldl ~ AOE 131 SEOVENTIAL no v!SKI rr NUM S II nvMesn Pal o, Verde Uni t 1 o s o o o 52 888 0 0 6 0 0,0 5 oF 05 TEKT //T wore spoof /1 coute/E ooo odc/'ono/rY/lc form 3/slA'ol 1131 surveillance testing. In particular, Licensee Event Report 87-007 for.

Unit 2 involved an inadequate tracking program to schedule surveillance testing. The corrective actions taken in response to these items were designed to address the identified "root causes". The effectiveness of the corrective actions varied largely on the specific circumstances of the event and the depa} tment involved. Although similar in nature to these events, this event is the first identified discrepancy of this kind within the responsible department. Therefore the corrective actions taken previously would not necessarily have prevented this occurrence.

However, as a prudent measure an independent review will be conducted to evaluate the overall tracking/identification systems for the assignment and completion of S.T.s. This evaluation will be designed to determine the effectiveness of previous corrective actions. Any recommendations, for enhancements made as a result of the evaluation, will be forwarded to the responsible management for review and implementation as appropriate.

4/lc ro/IQ sssn 19 dsi

t Arizona Nuclear Power Project P.O. BOX 52034 ~ PHOENIX. ARIZONA85072-2034 192-00368-JGH/TDS/DAJ April 19, 1988 U. S. Nuclear Regulatory Commission NRC Document Control Desk Washington, D.C. 20555

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Unit 1 Docket No. STN 50-528 (License No. NPF-41)

Licensee Event Report 88-006-00 File: 88-020-404 Attached please find Licensee Event Report (LER) No. 88-006-00 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. D. Shriver, Compliance Hanager at (602) 393-2521.

Very tr ly yours, J. G. H ynes Vice President Nuclear Production JGH/TDS/DAJ/kj Attachment CC: 0. H. DeHichele (all w/a)

E. E. Van Brunt, Jr.

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

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