ML17305A306

LER 89-010-00:on 890923,discovered That Surveillance Testing Interval for Radioactive Effluent Monitoring Sys Exceeded. Caused by Personnel Error.Human Performance Evaluation Sys Analysis of Error initiated.W/891017 Ltr

ML17305A306
Person / Time
Site:	Palo Verde
Issue date:	10/17/1989
From:	James M. Levine, Shriver T ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
192-00538-JML, 192-538-JML, LER-89-010-01, LER-89-10-1, NUDOCS 8910240251
Download: ML17305A306 (14)

Text

,ACCELERATED DI'S'7RIBUTION DEMONSTRA.TION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:8910240251 DOC.DATE: 89/10/17 NOTARIZED- NO DOCKET g FACIL:STN-50-530 Palo Verde Nuclear Station, Unit 3, Arizona Publi 05000530 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 R,

SUBJECT:

LER 89-010-00:on 890923,surveillance interval exceeded for radioactive effluent monitoring sys.

W/8 ltr. D DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:

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

NOTES:Standardized plant. 05000530

/

A RECIPIENT COPIES RECIPIENT COPIES LTTR ENCL D ID CODE/NAME LTTR ENCL ID. CODE/NAME PD5 LA 1 1 PD5 PD 1 1 DAVIS,M. 1 1 D INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 S ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 DEDRO 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/PEB 10 1 1 NRR/DOEA/EAB 11 1 1 NRR/DREP/RPB 10 2 2 NUDOCS-ABSTRACT 1 1 1 1 RES/DSIR/EIB 1 1 LE (H: 1 1 EXTERNAL: EG&G WILLIAMS,S 4 4 L ST LOBBY WARD 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 D

D NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WAS'ONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXI'. 20079) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 39 ENCL 39

4i 0

~,.7 0

Arizona Public Service Company PALO'VERDE NUCLEAR GENERATING STATION.

P 0 BOX 52034 ~ PHOENIX, ARIZONA 85072.2034 192-00538-JML/TDS/DAJ October 17, 1989 U. S. Nuclear Regulatory Commission NRC Document Control Desk Washington, D.C. 20555

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Unit 3 Docket No. STN 50-530 (License No. NPF-74)

L'icensee Event'eport 89-010-00 File: 89-013-00 Attached please find Licensee .Event Report (LER) No. 89-010-00 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 Manager at (602) 393-2521.

Very truly. yours,

. H., evine ice President Nuclear Production JGH/TDS/DAJ/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

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P~

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f NRC FORM 368 (54)9)

LICENSEE EVENT REPORT ILER) t APPROVED OMB NO. 31504104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REOUESTt 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (F530), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON. DC 20555. AND TO THE PAPERWORK REDUCTION PROJECT (31500104). OFFICE OF MANAGEMENTAND BUDGET. WASHINGTON. DC 20503.

FACILITYNAME (II DOCKET NUMBER (2) PAGE 3 TITLE Iel Palo Verde Unit 3 o so oo530ioF05 Surveillance Interval Exceeded for Radioactive Effluent Monitoring System EVENT DATE (5) LFR NUMBER (6) REPORT DATE. (7) OTHER FACILITIES INVOI.VED (8)

MONTH OAY YEAR YEAR SBOUBNTIAL VXvx REVIKre MONTH DAY YEAR FACILITYNAMES DOCKET NUMBER(s)

NUMBER ~CO NUMBER N/A 0 5 0 0 0 0 92 3 898 9 0 1 0 0 0 1 0 17 89 N/A 0 5 0 0 0 OPERATING THIS REPORT IS SUBMITTED PURSUANT T 0 THE RLDUIREMENTB oF 10 cFR g: Ichrch onr or mote of thr followinp/ (Ill MODE (8) 5 20A02(B)

, 20.405 I cl 50.73(e) 12) (ivl 73.71 (II)

POWER 20A05( ~ l(1 I Bl 60.38(cl(1) 60.73(el(2) (v) 73.71(cl LEYEL 1 0 0 20.405( ~ l(1((BI 50.38(cl(2) 50.73(e)(2)(v8) OTHER /Specify in Ahtttrct hV' l' VX V V'l 20.405(el(1((iii) hr/ow rntf in Trit, HRC Form 50.73(e I (2) I I) 60.73(e) (2)(riiil(A) 355AI 20A05( ~ I (I) (Iv) 50.73(e l(2)(ill 50.73(e)(2) (riii)(B) 20.405(el(1)(v) 50.73(el(2) (iii) 60.73(el(2) (xl LICENSEE CONTACT FOR THIS LER (12I NAME TELEPHONE NUMBER AREA CODE Timothy D. Shr iver, Compliance Manager 60 23 9 3 25 21 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBEO IN THIS REPORT (13)

CAUSE SYSTEM COMPONENT MANUFAC EPORTABLE...

NPRDS c

CAUSE SYSTEM COMPONENT MANUFAC. EPORTABLE TVRER TO TURER TO NPRDS I< It@tv(jt'~~Q,C;:

Hk%NIf)rl SUPPLEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR EXPECTED SUBMISSION DATE I'I5I YES Illyrt, compirtr EXPECTED SIIEht/SSIDII DATE/ X NO ABSTRACT /Limit to /400 tprcrt, Ir., rpptoxlmetrty fiftrrn tfnptr.corer typrrwittrn iinm/ (18)

At approximately 1535 MST on September 23, 1989 Palo Verde Unit. 3 was in Mode 5 (COLD SHUTDOWN) when a PVNGS technician (utility, non-licensed) discovered that the surveillance testing interval for the radioactive effluent monitoring system had been exceeded. The surveillance testing is required to be performed at least once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> pursuant to Specification 4.3.3.8 and was required to have been performed no later than 1500 MST on September 23, 1989 (this includes the 25 percent maximum allowable extension pursuant to Specification 4.0.2). The effluent monitoring system surveillance test was satisfactorily completed at approximately 1550 MST on September 23, 1989. The effluent monitoring system was administratively inoperable for approximately 50 minutes. There were no safety system responses and none were necessary.

The root cause of this event was a cognitive personnel error on the part of the PVNGS technician responsible for the performance of the surveillance testing. The technician neglected to perform the required daily surveillance testing in a timely manner.

A Human Performance Evaluation System analysis of the personnel error is being conducted and appropriate corrective actions will be taken.

Previous similar events occurred as discussed in Unit 2 LER 2-88-010 and Unit 3 LER 3-88-006.

NRC Form 388 (689)

tw NRC FORM ~~A US. NUCLEAR REGULATORY COMMISSION APPROVEO 0MB NO. 31500104 (BJ)9)

EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION REQUEST: 50A) HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P4)30), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, ANO TO THE PAPERWORK REDUCTION PROJECT (31500I04). OFFICE OF MANAGEMENTANO BUDGET,WASHINGTON, OC 20503.

FACILITY NAME (1) DOCKET NUMBER (2l LER NUMBER (5) PAGE (3) gN SEQUENTIAL r<jj REVISION NUMSSR ~>~i NVMSER Palo Verde Unit 3 o s o o o 5 3 0 8 9 01 0 00 02 OF 0 5 TEXT ///more Sr>>ee ls ~ II/urer/ cot /I)/4'>>/HRC Form 30//AS/ I IT)

DESCRIPTION OF WHAT OCCURRED:

A. Initial Conditions:

On September 23, 1989, Palo Verde Unit 3,was in Hode 5 (COLD SHUTDOWN) with the Reactor Coolant System (RCS)(AB) at approximately 100 degrees Fahrenheit and 331 pounds per square inch-absolute.

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

Event Classification: Conditions Prohibited by the Plant's Technical Specification At approximately 1535 HST on September 23, 1989, Chemistry Effluent personnel (utility, non-licensed) discovered that daily surveillance testing liad not been performed on the radioactive effluent monitoring system ( IL) pursuant to Technical Specification 4.3.3.8. The allowable surveillance interval had elapsed at approximately 1500 HST on September 23, 1989 for the Plant Vent System (VL) high and low range monitors (RU-143 and RU-144) and the Fuel Building Ventilation System (VG) high and low range monitors (RU-145 and RU-146).

Technical Specification Surveillance Requirement 4.3.3.8 specifies that the above monitors be demonstrated OPERABLE by the performance of a CHANNEL CHECK at least once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. These surveillance requirements are implemented via procedure 75ST-9ZZ07, "Effluent Honitoring System Daily Surveillance Testing." 75ST-9ZZ07, had been completed at approximately 0900 HST on September 22, 1989 and was due no later than 1500 HST on September 23, 1989 (This would include the maximum allowable extension of 25 percent delineated in Technical .Specification 4.0.2).

The performance of 75ST-91107 is the responsibility of a designated Chemistry Department Effluent Technician. At approximately 1535 HST on September 23, 1989 the responsible Chemistry Department Effluent Technician (utility, non-licensed) remembered that 75ST-9Z107 had not yet been completed. Investigation revealed that the maximum allowable extension for completing the surveillance had elapsed at approximately 1500 HST. Control room personnel (utility, licensed) were notified, the monitors were declared inoperable, and the appropriate actions were taken to complete the surveillance test. At approximately 1550 HST, the surveillance test (75ST-9ZZ07) was completed and the monitors were returned to an OPERABLE status.

NRC Form 3SSA ($ 09)

NRC FORM ESSA (LS. NUCLEAR REGULATORY COI/(MISSION APPROVEO OMB NO. 3(604104 (6491 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT {LER) INFORMATION COLLECTION REOUEST: 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P4301, U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (316001041. OFFICE OF MANAGEMENTAND BUDGET,WASHINGTON, OC 20503.

FACILI'TY NAME (11 DOCKET NUMBER (2l LER NUMBER (SI PAGE (31 YEAR ~

rmNC SEQUENTIAL NUM888

SVrSKIN gS NVM884 Palo Verde Unit 3 o 6 o o o 5 3 0 8 9 01 0 00 03 oF 0 5 TEXT /// mere e/rece /e rr/ee/ee/ eee /R/or 'oe/ NRC Form 36SA3/ (ITI C. Status of structures, systems, or components that were inoperable at the start of the event that contributed to the event:

Not applicable - there were no structures, systems, or components inoperable at the start of the event that contributed to the event. However, Radioactive Effluent Nonitoring System monitors described in Section I.B were administratively inoperable for approximately 50 minutes during the event.

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

Not applicable - no component or system failures were involved.

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

Not applicable - no component failures were involved.

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

Not applicable - no component failures were involved.

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 - no failures were involved which rendered a train of a safety system inoperable. However, the Radioactive Effluent Monitoring System monitors described in Section I.B were administratively inoperable for approximately 50 minutes.

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

Not applicable - there were no component or system failures or procedural errors.

Cause of Event:

The cause of the event was a cognitive personnel error on the part of the individual (utility, non-licensed) responsible for the performance of the surveillance testing. The responsible individual did not remember to perform the surveillance test in a timely manner. The error was not a result of an error in the approved procedure and was not a result of the activity not being covered by an approved procedure. There were no unusual NRC Form 366A (6891

4l Oi NRC FORMSSSA US. NUCLEAR REGULATORY COIrIMISSION APPROVEO 0MB NO. 3)500(04 (549)

EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: 50A) HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (F430), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON. OC 20555, AND TO THE PAPFRWORK REDUCTION PROJECT (3)500104). OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, OC 20503.

FACILITYNAME (II DOCKET NUMBER (2) LER NUMBER (5) PAGE (3)

YEAR )g 5 5 QV 5 NT I A NVMPER L;>g REVISION

~)o NVM89II Palo Verde Unit 3 o s o o o 530 8 9 01 000 04 OF 0 5 TEXT /// more epoce /e n /rrr)erL cae d /I/)eoM//I//ICForrrr 35549/ ()7) characteristics of the work location which contributed to the event.

J. Safety System Response:

Not applicable - there were no safety system responses and none were necessary.

K. Failed Component Information:

Not applicable - no component failures were involved.

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

There were no safety consequences or implications resulting from this event. Surveillance testing was successfully performed before and after the event. Therefore, the monitors were functional during the period of administrative inoperability and would have been capable of performing their intended function. Additionally, the high range monitors were not required during the period'f administrative inoperability as they are provided for tracking radioactive releases during postulated accident conditions. No accidents occurred which would have required operation of the high range monitors.

I I I. CORRECTIVE ACTIONS:

A. Immediate:

As immediate corrective action, the appropriate surveillance testing was completed on the radioactive effluent monitoring system and the monitors were returned to OPERABILITY.

B. Action to Prevent Recurrence:

As action to prevent recurrence, appropriate disciplinary measures have been taken. Additionally, a Human Performance Evaluation System analysis is being performed for the. personnel error and further corrective measures will be developed and implemented if necessary. A supplement to this report will be issued if substantial additional corrective measures are developed.

IV. PREVIOUS SIMILAR EVENTS:

Previous similar events involving the failure to perform daily radioactive effluent monitoring system surveillance testing were reported in Unit 2 LER 2-88-010 and Unit 3 LER 3-88-006. The corrective actions taken as a result of the previous events are considered adequate and could not have prevented the event described in the LER since this NRC Form 35SA (509)

li NRC FORM 3CSA U8. NUCLEAR REGULATORY COMMISSION APPROVEO OMB NO. 31500)04 (689)

EXPIRES: 4/30/92 I

ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION REQUEST: 50A) HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGFMENT BRANCH (F430). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (3150OIBCI. OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME I'l DOCKET NUMBER (2) LER NUMBER (5) PAGE (3)

YEAR SCOVCNTIAL;:u RCVISION NVMSCR NUMSCR Palo Verde Unit 3 o s o o o 53 08 9 01 000 05 oF 0 5 TEXT ///mors elrece /s //I/rerL use er/I/r)/orrellr/RC Fomr 3//SCB/()T) event was a result of cognitive personnel error. Additionally, the event described in Unit 2 LER 2-88-010 concerned an instance wherein the daily requirement to perform surveillance testing was misinterpreted to mean once per calendar day vice every 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.

Other events have been reported which involved surveillance testing not being performed within the specified interval. These events involved other PVNGS departments or circumstances not directly related to this event.

NRC Fanrr 3SSA (589)

II