ML17305A487

LER 88-015-02:on 881207,new Fuel Radiation Area Monitor RU-19 Discovered Inoperable.On 891204,radiation Surveys of Area Adjacent to New Fuel Storage Racks Not Performed. Caused by Malfunction in Monitor clock.W/900121 Ltr

ML17305A487
Person / Time
Site:	Palo Verde
Issue date:	01/21/1990
From:	Bradish T, James M. Levine ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
192-00621-JML-T, 192-621-JML-T, LER-88-015, LER-88-15, NUDOCS 9002020236
Download: ML17305A487 (16)

Text

ACCELERATED+ISTS'JBUTION DEMOb+RATION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9002020236 DOC.DATE: 90/01/21 NOTARIZED: NO DOCKET FACIL:STN-50-529 Palo Verde Nuclear Station, Unit 2, Arizona Publi 05000529 AUTH. NAME AUTHOR AFFILIATION BRADISH,T.R. 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 88-015-02:on 881203,action statement not met for inoperable radition monitor.

W/8 ltd.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE: /

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/DET/ECMB 9H 1 1 NRR/DET/EMEB9H3 1 1 NRR/DET/ESGB 8D 1 1 NRR/DLPQ/LPEB10 1 '

NRR/DLPQ/LHFBl1 1 1 NRR/DOEA/OEAB11 1 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB 8D 1 1 NRR/DST/SICB 7E 1 1 NRR~DSTQ S PLB8 Dl 1 1 NRR/DST/SRXB 8E 1 1 G 1 1 RES/DSIR/EIB 1 1 RGN5 FILE 01 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 NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOM P 1-37 (EXT. 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

ll 0 Arizona Public Service Company PALO VERDE NUCLEAR GENERATING STATION P.O BOX 52034 ~ PHOENIX. ARIZONA 85072-2034 192-00621-JML/TRB/RKR JAMES M. LEVINE January 21, 1990 VICE PRESIDENT NUCLEAR PRODUCTION U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

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

Licensee Event Report 2-88-015-02 File: 90-020-404 Attached please find Supplement Number 2 to Licensee Event Report (LER) No.

88-015-00 prepared and submitted pursuant to 10CFR50.73. In accordance with 10CFR50.73(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, (Acting) Compliance Manager at (602) 393-2521.

Very truly yours, JML/TRB/RKR/kj Attachment cc: W. F. Conway (all with attachment)

E. E. Van Brunt J. B. Martin D. Coe M. J. Davis A. C. Gehr INPO Records Center

- c.~q

~-"< 9O O~OOO'.

2 8'N

'j21

.yOo202<

PAIR AXIOC PDC f/)

0 (64)9)

'.S.

NRC FORM 365 FACILITY NAME (II LICENSEE EVENT REPORT ILER)

NUCLEAR REGULATORY COMMISSION 'APPROVED OMB NO. 31500104 EXPIRES. 4/30/02 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P430), V.S/ NUCLEAR REGULATORY COMMISSION. WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

DOCKET NUMBER (2) PA E 3 Palo Verde Unit 2 o s o o o 5 29 ioFp6 TITLE (il

.Action Statement not Met for Inoperable Radiation Monitor EVENT DATE (5) LER NVMBER (6) REPORT DATE (7I OTHER FACILITIES INVOLVED (8)

MONTH DAY 'EAR YEAR @%: sEQUSNTIAL NUMBER PoSc 8 t. VISION MONTH NUMBER

'AY YEAR PACILITYNAMES DOCKET NUMBERISI N/A 0 5 0 0 0 1 2 0 3 8 8 8 8 0 1 5 0 2 01 21 90 N/A 0 5 0 0 0 THIS REPOR'T IS SUBMITTED PURSVANT 7 0 THE RLQVIREMENTS OF 10 CFR ()I /Cnrcp onr of more ol the lopowinpl (11 OPERATING MODE (8) 20.402 (8) 20.405(cl 60,73I ~ )(2)(iv) 73.7((8) 1 POWER 20.405(e) (1)(i) 50.38(e)11) 50.73(e)(2)(v) 73.7 1(c)

LEVEL OTHER /Specify /n Aostrect p p 1 20.405 (~ ) (I ) (ii) 60.38(c)(2), 50,73( ~ l(2) (vii)

OrlOw mr/ in Trit, SY/IC FOrm 20.405( ~ ) (1)(iii) 50.73( ~ l(2)(i) 60,73(e) (2)(viii)(Al 3ESA/

20A05(e) l(l(iv) 50.73( ~ )(2)(ii) 60.73(e) (2) (vli I) (Bl 20.405( ~ )(1)(v) 5073(e)(2)liii) 60.73(e)(2)(x)

LICENSEE CONTACT FOR THIS LER (12I NAME TELEPHONE NUMBER AREA CODE Thomas R. Bradish, (Acting) Compliance Manager 60 23 9 3 25 21 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13l EPORTABLE MANUFAC. EI'ORTABLE

'2cg~g'g@gjgS'i SYSTEM COMPONENT MANUFAC '

C*IISE STE COMPONENT CAUSE TVRER TO NPRDS 5 TVRER TO NPRDS X I I K I K 0 2 0 itisvsrstZ~'was:cev:.

8'~v%1!8Ã(TIE SUPPLEMENTAL REPORT EXPECTFD (14) MONTH OAY YEAR EXPECTED SUBMISSION DATE (15)

YES lit yrs, compirtr EXPECTED Si/SM/$$ /ON //ATE/

ABSTRACT /Limit ro /400 gwcrL l.e., eppsoiimerely lifurn slnpfr.spree ryprwsitrrn linrs/ (181 On December 7, 1988 at approximately 0942 MST, a Unit 2 Chemisery Technician (contractor, non-licensed) discovered the new fuel area radiation monitor RU-19 was inoperable. RU-19 indicated a constane O.OOE-O millirem per hour radiation level instead of actual level. RU-19 measures area. radiation adjacent to the new fuel storage racks. A review of previous readings determined that the lase accuraee reading occurred on December 3, 1988 at approximately 0516 MST. On December 4, 1988 at approximately 0516 MST, 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 MST, the area monitor RU-19 was reset, tested, and declared operable.

NRC Form 385 (64)8)

.0 0 NRC FORM366A US. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 31500)04 (669 I EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT. REPORT ILER) INFORMATION COLLECTION REOUESTI 50A) HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENTBRANCH (F430), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555. AND TO THE PAPERWORK REDUCTION PROJECT (31504)104). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON. OC 20503.

FACILITY NAME (I) DOCKET NUMBER 12) LER NUMBER (6) PAGE (3)

SEOUENTIAL REVISION YEAR NUMSEII 'CK NUMOER Palo Verde Unit 2 TExT illmoro Sootoit tor)rrptd. Uto oddrtioool HRc Form 3N4'tl ()T) 0500052988 015 02 02 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.

Reportable Event Description (Including Dates and Approximate Times of Major Occurrences):

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

On December 7, 1988 at approximately 0942 MST, 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 O.OOE-OO 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 O.OOE-OO millirem per hour at the monitor was found to be reading local indicator and thus, was not displaying the actual radiation in the area. The Shift Supervisor (utility, licensed) was notified on the inoperable monitor, and he initiated action to compensate for the condition.

At approximately 1015 MST on 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 MST on December 7, 1988.

The Chemistry Technician investigated the hourly printout of the monitor and found the last apparent accurate reading occurred at approximately 0516 MST on December 3, 1988. With the monitor inoperable, Technical Specification 3.3.3.1 ACTION 22 requires NRC Form 366A (669)

ik I~

J I

NAC FORM 3SSA US. NUCLEAR REGULATORY COMMISSION 0 APPROVEO 0MB NO. 3'I500104 (64)9)

E XP I R 5 3: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INI'ORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (PJ)30), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (11 DOCKET NUMBER (2) LEA NUMBER IS) PAGE (3)

YEAR K4 SEQUENTIAL NUMBER 9(ro REVISION NUMSFR Palo Verde Unit 2 o o o o o 5 2 9 8 8 0 1 502 03 OF 0 6 TEXT ///moro 4/>>co /4 roar/rod, Iroo oddrdor>>/HRC Form 3SIIA3/()7) 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 scheduled weekly surveys. This survey showed no abnormal radiation levels in the area.

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.

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 co'mponents with multiple functions, list of systems or secondary functions that were also affected:

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

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

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

NRC Form 355A (589)

IP k

NRC FORM SSSA US. NUCLEAR REGULATORY COMMISSION APPROVED 0MB NO. 31600104 (64)S)

EXPIRES: 4/30N2 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: SOA) HRS. FORWARD COMMENTS REQAROINQ BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS, MANAGEMENT BRANCH (P4)30). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31604)104). OFFICE OF MANAGEMENTAND BUDGET,WASHINGTON, DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3) rlSvrsr0N YEAR m6 ssoUENTIAL

~ lUMSSII '.gjc.'rUM Srl r

Palo Verde Unit 2 0 5 0 0 0 5 2 9 88 0 15 02 0 4 oF 0 6 TEXT (JF moro Ppoco )4 rodrrPod, rroo oddi5orrol NRC Form 36643) (17)

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

The failure of the monitor was discovered during a review of Technical Specification monitor's.

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 performer to obtain a computer display of the operational status of all the monitors in the system. A non-flashing, green '1'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 '1'ppeared. This is the acceptance criterion given in step 8.1.1, which ends with the instruction "..record results in Appendix A."

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.

NRC Form 366A (64)S)

0 NRC FORM 366A US, NUCLEAR RFGULATORY COMMISSION API'ROVED 0MB NO. 31500104 (609)

EXPIRES: 4/30)92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION REGUESTI 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (F430), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON. DC 20503.

FACILITYNAME (ll DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

SEQUENTIAL ('%EVISION YEAR NUMSER re NIJMSER Palo Verde Unit 2 o s o o o 52 988 0 15 02 0 5 0 6 TEXT IIImoss spsso Js Isqor)od, uss sddr(r'ORSI HRC Form 3664's) (17)

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.R 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 t'e 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-NRC Form 366A (669)

. ~ II NRC FORM366A U.S. NUCLEAR REGULATORY COMMISSION (64)9) APPROVED OMB NO. 31500104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT {LER) INFORMATION COLLECTION REQUEST: 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P.530). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (3)S00(04), OFFICE OF MANAGEMENTAND BUDGET,WASHINGTON, DC 20503.

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

YEAR cd SEQUENTIAL NUMBER

>~(' REVISION NVMSER Palo Verde Unit 2 o s 0 o o 529 88 0 1 5 0 2 06oF 06 TEXT lllmors <<rss>> /s rsrrrrirsd, oso sddirS)os/ NRC Form 366A'4/ (17) as required by the Technical Specifications. This was completed at approximately 1015 MST on December 7, 1988. Additionally, the moni'tor was reset and operated properly. Thus, at approximately 1030 MST 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.

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 Monitoring 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.

February 15, 1990.

The training received by the performance group responsible for shiftly surveillance of the Radiation Monitoring System has been evaluated and the training has been revised to implement the results of the evaluation.

IV. PREVIOUS SIMILAR EVENTS:

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

NRC Form 366A (669)

il 0