ML17305A274

LER 89-015-01:on 881203,discovered New Fuel Area Radiation Monitor RU-19 Inoperable.Caused by Personnel Error.Radiation Monitoring Sys Surveillance Procedure Being Revised to Clarify instructions.W/891003 Ltr

ML17305A274
Person / Time
Site:	Palo Verde
Issue date:	10/03/1989
From:	James M. Levine, Shriver T ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
162-00533-JML, 162-533-JML, LER-89-015, LER-89-15, NUDOCS 8910120140
Download: ML17305A274 (16)

Text

AC CELE RATED 1

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DEMON STRATI 0. i SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RZDS)

ACCESSION NBR:8910120140 DOC.DATE: 89/10/03 NOTARIZED: NO DOCKET FACXL:STN-50-529 Palo Verde Nuclear Station, Unit 2, Arizona Publi 05000529 AUTH. NAME AUTHOR AFFILIATION SHRIVER,T.D. Arizona Public Service Co. (formerly Arizona Nuclear Power LEVINE,J.M. Arizona Public Service Co. (formerly Arizona Nuclear Power RECIP. NAME RECIPIENT AFFILIATION

SUBJECT:

LER 89-015-01:on 881203,action statement not met for inoperable radiation monitor.

W/8 ltr.

DISTRIBUTION CODE IE22T COPIES RECEIVED:LTR ENCL 'IZE:

TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES:Standardized plant. 05000529 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD5 LA 1 1 PD5 PD 1 1 CHAN,T 1 1 DAVIS,M 1 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 DEDRO 1 1 NRR/DEST/CEB 8H 1 1 NRR/DEST/ESB SD 1 1 NRR/DEST/ICSB 7 1 1 NRR/DEST/MEB 9H 1 1 NRR/DEST/MTB 9H 1 1 NRR/DEST/PSB SD 1 1 NRR/DEST/RSB 8E 1 1 NRR/DEST/SGB SD 1 1 NRR/DLPQ/HFB 10 1 1 NRR/DLPQ/PEB 10 1 1 NRR/DOEA/EAB 11 1 1 NRR/PREP/ PB 10 2 2 NUDOCS-ABSTRACT 1 1 G FILE 1 1 RES/DSIR/EIB 1 1 GNS FZQ> 01 1 1 EXTERNAL: EG&G WILLIAMSi S 4 L ST LOBBY NARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC MAYS,G 1 1 NSIC MURPHY,G.A 1 1 NUDOCS FULL TXT 1 1 NOTES 1 1 NVZE K) ALL '%IKS" RECZPXIKIS~

PZEASE iUKiP US XQ RPXXRE %hfKEf CXKZACI.'IHE DOCUMENTS CXÃISOL DESKi RXM P1-37 (EXT. 20079) %0 RKiQCQMS RXSt NWS HCK DIBXRIBUZXCN LISTS XQR DQCQHRRXS VXJ DCSERT NREDf FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 41 ENCL 41

Arizona Public Service Company

'PALO VERDE NUCLEAR GENERATING STATION P,O, BOX 52034 ~ PHOENIX. ARIZONA 85072-2034 192-00533-JML/TDS/RJR October 3, 1989 U. S. Nuclear Regulatory Commission NRC Document Control Desk Washington, D.C. 20555

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

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

Licensee Event Report 88-015-01 File: 89-020-404 Attached please find Supplement Number 1 to Licensee Event Report (LER) No.

88-015-00 prepared and submitted pursuant to the requirements of 10CFR 50.73.

In accordance with 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 Manager at (602) 393-2521.

Very truly yours, J. H. Levine Vice President Nuclear Production JGH/TDS/RJR/kj Attachment CC: W. F. Conway (all w/a)

E. E. Van Brunt, Jr.

J. B. Hartin T. J. Polich H. J. Davis A. C. Gehr INPO Records Center 35'10120140 391003 PbR AEIOCK 0 000525 PDC

I' NRC Sotm 244 U.S. NUCLEAR RKOULATORY COMMISSION (903 l AppRDYED DMs Noi 21504(04 LICENSEE EVENT REPORT ILER1 f XPIRESI ~ ISIISS FACILITY NAME OI DOCKET NUMSER (2) PA TITLE Iel Palo Verde Unit 2 o 5 oo o 5291OF06 Action Statement not Het for Inoperable Radiation Monitor EVENT DATE (Sl LER NVMSER (SI REPORT DATE (7) OTHER FACILITIES INVOLVED LS)

SEOVENTIAL PC RevtetOte MONTH O*Y PACILI'TY NAM55 DOCKET NUMBER(5)

MONTH OAY YEAR YEAR NVM44 R V'i NVM45R YEAR III/A 0 5 0 0 0 1 2 0 3 8 8 8 8 ,01 5 01 10 03 89 N/A 0 5 0 0 0 THIS REPORT IS SUSMITTED PURSUANT T 0 THE REOUIRKMfNTS OF 10 csR (): Icneco one or more or tne Iollowingl IIII OPERATINO MODE ( ~ ) 20A02(4) 1 ~ 20.405(c) 50.72(e)(2)lhl Tl.71(4)

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LICfNSEE CONTACT SOR THIS LKR (12)

NAME TELEPHONE NUMSER AREA CODE Timothy D. Shriver, Compliance Manager 60 23 93 2 52 1 COMtLKTE ONK LINK SOll EACH COMtONENT SAILURE OfSCRISED IN THIS REPORT (12)

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On December 7, 1988 at approximately 0942 HST, a Unit 2 Chemistry Technician (contractor, non-licensed) discovered the new fuel area radiation monitor RU-19 was inoperable. RU-19 indicated a constant O.OOE-O millirem per hour radiation level instead of the actual level. RU-19 measures area radiation adjacent to the new fuel storage racks. A review of previous readings determined that the last accurate reading occurred on December 3, 1988 at approximately 0516 HST. On December 4, 1988 at approximately 0516 HST, area surveys were not performed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> as required by Technical Specifications 3.3.3. 1 Action 22.

The cause of the inoperable monitor is believed to be a malfunction of a clock in the computer internal to the monitor. A root cause of failure was unable to confirm the cause. The cause of the missed action statement requirements is a cognitive personnel error contrary to an approved procedure. As immediate corrective action, on December 7, 1988 at approximately 1030 HST, the area monitor RU-19 was reset, tested, and declared operable.

NRC Seem 544

(Qi NAC FORM 368A U.S. NUCLEAR REGULATORY COMMISSION APPROVEO OMB NO. 31500104 (869),

EXPIRES: 4/30/92 ESTIMATED BUADEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFOAMATION COLLECTION AEQUESTI 500 HAS. FORWARD COMMENTS RFGAAOING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPOATS MANAGEMENT BRANCH (P4)30). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104). OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, OC 20503.

FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (8) PAGE (3)

, SEOUENTIAL NVMSER s+iN(

REVISION NUMSER Palo Verde Unit 2 o so o o 52 98 8 0 1 5 01 0 2oF 0 6 TEXT /lfmoro Jpoco /I ooRI/&rod, ooo oddicorro/HRC Farm 368r('4)(12)

DESCRIPTION OF WHAT OCCURRED:

A. Initial Conditions:

Unit 2 was in Mode 1 (POWER OPERATION) at approximately 100 percent reactor power on December 3 through 7 during the entire period of this event. The Unit was in the second fuel cycle; thus, spent fuel existed in the fuel pool.

B. Reportable Event Description (Including Dates and Approximate Times of Hajor Occurrences):

Event Classification: Condition Prohibited by the Plant's Technical Specifications.

On December 7, 1988 at approximately 0942 NST, a Unit 2 Chemistry Technician (contractor, non-licensed) discovered that the new fuel area radiation monitor RU-19 did not indicate properly and was inoperable. The Chemistry Technician was performing checks of Technical Specification (TS) monitors when, he obtained a reading of 0.00E-00 millirem per hour on the Display Control Unit (DCU) for RU-19. In reviewing the daily averages for the previous three days on the DCU he found those also read O.OOE-OO millirem per hour.

The Chemistry Technician (contractor, non-licensed) then checked to determine if the monitor was operating locally. The monitor was found to be reading O.OOE-OO millirem per hour at the local indicator and thus, was not displaying the actual radiation in the area. The Shift Supervisor (operator, licensed) was notified on the inoperable monitor, and he initiated action to compensate for the condition.

At approximately 1015 HST December 7, 1988, a radiation survey'was taken in the area, and levels were found to be normal and within specification.

The Radiation Protection Technician (utility, non-licensed) reset the monitor by turning it off and then on again. The local indication then responded normally, and setpoints were verified satisfactory. Based on these results, the monitor was declared operable at approximately 1030 December 7, 1988.

The Chemistry Technician investigated the hourly printout of the monitor and found the last apparent accurate reading occurred at approximately 0516 HST December 3, 1988. Technical Specification 3.3.3. 1 ACTION 22 requires area surveys of the monitored area at least once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. The only radiation survey of the monitored area during this event was on December 5, 1988 as part of NRC Form 366A (869)

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NRC FORM SSSA U.S. NUCLEAR REGULATORY COIEMISSION APPROVED OMS NO. 31500104 (SS9)

EXPIRES: 4/30/92 ESTIMATED SURDFN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING SUROEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P4)30). U.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104). OFFICE OF MANAGEMENTAND SUDGET, WASHINGTON, OC 20503.

FACILITYNAME (I) DOCKET NUMSER (2) LER NUMSER (5) PAGE (3) g'%EQUENTIAL ~+X REVrSION NUMEEII:..5 NUMEER Palo Verde Unit 2 o s o o o 52 98 8 0 1 5 01 0 3 oF0 6 TEXT ///moro 4/roco /4/or/rr/rorL rr>> or)/ 'orro/HRC Farm BASSA'4)(17) scheduled weekly surveys. This survey showed no abnormal radiation levels in the area.

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

Other than RU-19, no other structures, systems; or components were inoperable at the start of this event that contributed to this event.

D. Cause of each component or system failure, if known:

Since the monitor was turned off and then back on, the problem has not recurred. On December 3, 1988, the clock in the monitor's computer appears to have malfunctioned. This clock is necessary to tell the computer to update the raw data provided by the detector into a radiation reading each second. With the clock malfunctioned, the monitor will not perform the calculation and the readout will be zero, as observed. When the monitor was reset by turning it off and back on, the computer initialization program reset the clock which then allowed the monitor to operate normally. The data collected did not provide objective evidence of a component failure. Thus, the Engineering Evaluation was unable to positively identify a root cause of failure.

E. Failure mode, mechanism, and effect of each failed component, if known:

The failure in the monitor caused the Display Control Unit (DCU) to read zero.

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

Not applicable - RU-19 provides an alarm action at a present level and has no automatic features. It also does not provide multiple functions.

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

Not applicable - RU-19 is not a safety-related monitor.

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

The failure of the monitor was discovered during a review of NRC Form 35SA (SSS)

(Qi 4

/

NRC FORM 366A U.S. NUCLEAR REGULATORY COIAMISSION APPROVED OMB NO. 31500104 (64)9)

EXPIRES'. 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION REOUEST: 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND RFPORTS MANAGEMENT BRANCH IP430). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31504))04). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON,OC 20503.

FACILITY NAME ll) DOCKET NUMBER l2) LER NUMBER (6) PAGE (3)

SEQUENTIAL REVrSION NUMSSII Ã5 rrUM66A Palo Verde Unit 2 o s o o o 52 988 0 1 5 01 04oF 0 6 TEXT /rf mare 4aeee /4//r/rer/ rree aeT/Or/en/ IYRC FrNm 366A'4/(17)

Technical Specification monitors.

I. Cause of Event:

The failure to recognize the inoperability of RU-19 was cognitive personnel error by the Control Room Operator (utility licensed) based on a misinterpretation of procedural instructions in the Surveillance Test. The Control Room Operator believed that the successful performance of step 8. 1. 1 of the Surveillance Test procedure was sufficient for the determination of OPERABILITY for RU-19. However, Appendix A of 42ST-2ZZ34 requires the performance of the second step (8. 1.2).

Step 8. 1. 1 of the Surveillance Test instructs the test performed to obtain a computer display of the operational status of all the monitors in the system. A non-flashing, green ormally indicates that a monitor channel is functioning properly and no alarms are present. If some other indication appears, the test performer is instructed to obtain the data base display for that channel for further evaluation. For the six performances of the Surveillance Test during the RU-19 inoperability, a non-flashing, green ppeared. This is the acceptance criterion given in step

8. 1. 1, which ends with the instruction "..record results in Appendix A.H Step 8. 1.2 instructs the performer to obtain an hourly trend display for each monitor listed in Appendix A and evaluate the data per step 8. 1.2.1, which states: "Further evaluate these one hour average readings by performing the following steps:

Verify that the current hourly average is consistent with current plant conditions.

Verify that any trends indicated by the 24 hourly averages were consistent with plant conditions during the same time frame.

Any SPIKE in the hourly averages of greater than 1 (one) decade from the current hourly average reading should be evaluated and documented in the test log.

If any inconsistencies occurred in any of the 3 (three) previous'steps, request that RP perform an evaluation of the monitor and document it in the test log.H NRC Form 366A (669)

NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED 0MB NO. 3)500104 (669)

E XP I R E S: 4/30/92 FSTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN FSTIMATE TO THE RECORDS TEXT CONTINUATION ANO REPORTS MANAGEMENT BRANCH (F430). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON. DC 20555. ANO TO THE PAPERWORK REDUCTION PROJECT (31504104). OFFICE OF MANAGEMENTAND BUDGET. WASHINGTON, DC 20503.

FACILITY NAME (() DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL pjw REVISION NUMSER Yrt NUMBER Palo Verde Unit 2 o s o o o 5 2 9 8 8 01 5 0 1 0 5oF 0 6 TEXT IIImom tottoit toOIt)od, oto tddidoINI IVRC Fomt 3664'4) (17)

No data is required in Appendix A, as the acceptance criteria only requires a "yes, no, or not applicable" be circled and the initials of the performer. Step 8. 1. 1 states, "Evaluate the data base display to determine if the monitor is OPERABLE. Record results in APPENDIX A". Thus, the test performer did not obtain and evaluate the hourly trend data, although the procedure does not provide for omitting step 8. 1.2, and Appendix A specifically refers to step

8. 1.2 for the acceptance criteria. Had step 8. 1.2 been performed,.

the change from variable readings to consistently zero readings would have been recognized and could have been investigated.

J. Safety System Response:

Not applicable - no safety system response was required or anticipated.

K. Failed Component Information:

RU-19 is a Kaman monitor model number 952109-001.

II. ASSESSMENT OF THE SAFETY CONSEQUENCES AND IMPLICATIONS OF THIS EVENT:

The OPERABILITY of the radiation monitoring channels ensures that: (1) the radiation levels are continually measured in the areas served by the individual channels and (2) the alarm is initiated when the radiation level trip setpoint is exceeded.

RU-19 is the area radiation monitor for the new fuel area of the fuel building. A second monitor is also located in the building and monitors the spent fuel area. Since the second monitor (RU-31) was operable throughout the event and since only spent fuel was in the fuel building at the time of the event, no safety hazards existed during the period of inoperability. Thus, this event represents no impact to the health and safety of the public.

III. CORRECTIVE ACTIONS:

A. Immediate:

As immediate corrective action, a survey of the area was conducted as required by the Technical Specifications. This was completed at approximately 1015 on December 7, 1988. Additionally, the monitor was reset and operated properly. Thus, at approximately 1030 HST on December 7, 1988 RU-19 was declared operable. A work request was submitted to troubleshoot the cause of the malfunction and replace or rework as necessary. However, the problem has not recurred and no further action on the work request has occurred.

NRC Form 366A (669)

,L 0 ((

NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 31500104 (64)9)

EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P4)30), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500'l04). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

SSQUSNTIAI ~ii: IISVIS ION NUMSSII %Id NUM 6 II Palo Verde Unit 2 o s o o o 5 2 9 8 9 01 5 01 0 6oFO 6 TEXT ///more Spece /4 r/II/bred. o44 edd)/Oooo/HRC %%dmr 3564'4/ (17)

The Shift Supervisor (utility, licensed) informed Units 1 and 3 of the incident.

Unit 2 issued a night order to Operations directing that if a zero reading is received while performing the Surveillance Test, investigation is necessary to insure the zero reading is valid and the monitor is operating properly.

B. Action to Prevent Recurrence:

Changes in the configuration of the monitor were considered not possible due to internal constraints of the computer. The software cannot determine when a current radiation reading is valid or not.

Each monitor reports currently indicated conditions which must be .

analyzed with all other data available. Operational procedures will therefore continue to be used to validate parameters and operability of the monitor.

As action to prevent recurrence of the Human Performance problems identified in this event, the following actions are being taken:

The Radiation Honitoring System surveillance procedure is being revised to clarify instructions, acceptance criteria, and guidance on evaluation of a monitor's ability to perform its function. This revision is expected to be complete by October 31, 1989.

The training received by the performance group responsible for shiftly surveillance of the Radiation Honitoring System will be evaluated and upgraded as necessary. The completion of this task is expected by November 30, 1989.

IV ~ PREVIOUS S IHILAR'VENTS:

Although LERs have been submitted on the Radiation Honitoring System, this particular problem has not been previously reported.

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