ML17305A812

LER 88-015-03:on 881203,chemistry Technician Discovered That New Fuel Area Radiation Monitor RU-19 Inoperable.Caused by Malfunction of Clock in Computer Internal to Monitor. Monitor Reset & Operated properly.W/900518 Ltr

ML17305A812
Person / Time
Site:	Palo Verde
Issue date:	05/18/1990
From:	Bradish T, James M. Levine ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
192-00665-JML-T, 192-665-JML-T, LER-88-015, LER-88-15, NUDOCS 9005290092
Download: ML17305A812 (18)

Text

ACCELERATED STRIBUTION DEMON MA.TION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9005290092 DOC.DATE: 90/05/18 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 88-015-03:on, 881203,action statement not met for inoperable radiation monitor.

W/9 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 PETERSON,S. 1 1 CHAN,T 1 1 INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DS P 2 2 DEDRO 1 1 NRR/DET/ECMB 9H 1 1 NRR/DET/EMEB9H3 1 1 NRR/DLPQ/LHFB11 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB11 1 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB 8D 1 1 NRR/DST/SICB 7E 1 1 PLB8Dl 1 1 NRR/DST/SRXB 8E 1 1 E 02 1 1 RES/DSIR/EIB 1 1 RGN5 FILE 01 1 1 EXTERNAL EG&G STUART i V A 4 4 L ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC MAYS, G 1 1 I NS C MURPHY i 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 Pl-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 38 ENCL 38

4l Arizona Public Service Company PALO VERDE NUCLEAR GENERATING STATION P.O. BOX 52034 ~ PHOENIX. ARIZONA85072-2034 JAMES M. LEVINE 192-00665-JML/TRB/RKR VICE PRESIDENT NIICI.EAIIPRDDUCTION May 18, 1990 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 2-88-015-03 File: 90-020-404 Attached please find Supplement Number 3 to Licensee Event Report (LER) No.

88-015-00 prepared and submitted pursuant to 10CFR50.73. This report is being submitted to update the schedule for implementing the corrective actions. 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, Compliance Manager at (602) 393-2521.

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

J. B. Martin D. H. Coe T. L. Chan A. C. Gehr A. L. Gutterman INPO Records Center

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i NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION (64)9) APPROVED OMB NO. 31504)104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD LICENSEE EVENT REPORT {LER) COMMENTS REGARDING BURDEN ESTIMATE TO THE RECOADS AND REPORTS MANAGEMENT BRANCH (F630), U.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON, OC 20555. AND TO THE PAPERWORK REDUCTION PROJECT (31500104). OFF ICE OF MANAGEMENTAND BUDGET. WASHINGTON/DC 20503.

FACILITY NAME (I) DOCKET NUMBER (2) PAGE 3 TITLE (4)

Palo Verde Unit 2 o 5 o o o 529 > OF07 Action Statement not Met for Inoperable Radiation Monitor EVENT DATE (5) LER NUMBER LS) REPORT DATE (7) OTHER FACILITIES INVOLVED (6)

MONTH DAY YEAR YEAR SEQUENTIAL ~rrOP IIEVISION MONTH DAY YEAR FACILITYNAMES DOCKET NUMBER(S)

NUMBER Wrr NVMSEII N/A 0 5 0 0 0 12 03 88 88 01 5 03 0 5 189 N/A 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT T O THE REQUIREMENTS OF 10 CFR ()r /Check onr or morr of the forlovvinp/ 01)

OPERATING MODE (9) ] 20.402(tr) 20.405(c) 50,73(al(2)(iv) 73.71(bl POWER 20A05( ~ ) (1)(il 50M(c)(1) '0.73(s l(2) (v) 73.71(c)

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LICENSEE CONTACT FOR THIS LEA (121 NAME TELEPHONE NUMBER

'9.3-2 AREA CODE Thomas R. Bradish, Compliance Mana er 60 521 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE SYSTEM COMPONENT MANUFAC.

TVRER EPOATABLE r:~ 5(Q~ CAUSE SYSTEM COMPONENT MANUFAC.

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X IL KI K 020 St()Mrxp SVI'PLEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR FXPECTED SUBMISSION DATE (15I YES Ilfyrr, complete EXPECTED SVpar/SSIOH DATE/ NO ABSTRACT /Limit tO /400 aprcerr I e., approx/merely fifteen rlnplr opere ryoevrrlrtrn lineal (14)

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 was inoperable. RU-19 indicated a constant 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 last accurate 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 however 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.

There have been no previous similar events reported pursuant to 10CFR50.73.

NRC Form 355 (669)

Qi NAC FORM 3SSA US. NUCLEAR REGULATORY COMMISSION APPAOVEO 0MB NO. 31500104 (e()S)

EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION AEOUESTI 50)) HRS. FORWARD COMMENTS REGARDING BUADEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPOATS MANAGEMENT BRANCH (F430). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31504)(04). OFFICE OF MANAGEMENTAND BUDGET,WASHINGTON;DC 20503.

FACILITY NAME (ll DOCKET NUMBER (2) LER NUMBER (5) PAGE (3)

YEAR SEQUENTIAL REVISION NVM ER NVMSER Palo Verde Unit 2 o s o o o 529 88 015 03 02 oF 07 TEXT N more spsse )s rsOIdrsd, oss sddr'O'orISI PIRC form 3SSA's) (17)

DESCRIPTION OF WHAT OCCURRED'.

Initial Conditions:

Unit 2 was in Mode 1 (POWER OPERATION) at, approximately 100 percent reactor power on December 3 through 7 during the entire peribd 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 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 (utility, licensed) was notified of the inoperable monitor, and 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 and setpoints were verified indication then responded normally, 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 NAC Form 34SA (BSQ)

~ i i NRC FORM355A U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO,31500104 (54)9)

EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMI'LY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: 50.0 HAS. FOAWARD COMMENTS REGARDING BURDEN FSTIMATE 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 (31504104). OFFICE OF MANAGEMENTAND BUDGET,WASHINGTON, DC 20503.

FACILITY NAME (I) DOCKET NUMBER (2) LER NUMBER LB) PAGE (3)

YEAR SEQUENTIAL ~rr'Cr REVISION NUMSER dor NUMSER Palo Verde Unit 2 o 5 o o o 5 2 9 8 8 0 1 5 03 03 OF 0 7 TEXT /I/mort tot ot /4 rth/u/rtd. utt tdChl/one/ //RC Form 3554'4/ () 1) 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.

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 was unable to 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 clock malfunction in the monitor caused the Display Control Unit (DCU) to read, zero.

F. 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 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.

NAC Form 366A (669)

i' NRC FORM 344A U.S. NUCLEAR REGULATORY COMMISSION APPROVED 0MB NO. 31504)OO (449)

EXP IR ES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (F430). U.S NUCLEAR REGULATORY COMMISSION. WASHINGTON. DC 20555i AND TO THE. PAPERWORK REDUCTION PROJECT 131504)CO). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (11 DOCKET NUMBER (2) LER NUMBER LS) PAGE (3)

'A'N SEQUENTIAL IIEyrSKJN YEAR NUM ER '"

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o NUM444 Palo Verde Unit 2 05000'529 88 015 0 3 0 4 QF 0 7 TEXT /llmoro gvco /1 ror/vkrd, ooo odd/a'arro/ HRC Farm 344AB/ () 7)

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

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

Cause. of Event:

The failure to recognize the inoperability of RU-19 was cognitive personnel error by the Control Room Operator (utility, li'censed) based on a misinterpretation of procedural instructions in the Surveillance Test. The Control Room Operator believed that the successful performance of step 8.l.l,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'hese 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) d'ecade from the current hourly average reading should be evaluated and documented in the test log..

NRC Form 344A (449)

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NRC FORM365A US. NUCLEAR REGULATORY COMMISSION APPAOVED OMB NO. 31500104 (54)9)

E XPIR ES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: 50J) HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P430), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31504)104). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (11 DOCKET NUMBER (2) LEA NUMBER (5) PAGE (3)

YEAR SEOVENWAL REVISION NUMBER NUMSER Palo Verde Unit 2 o 5 o o'o 52 88 0 1 0 3 0 5 QF 0 7 TEXT /lfmoro spese /4 ler/Irlrer/ use edr/ro'oos/ HRC Form 35543/ (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."

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.

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 bu'ilding 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.

NAC Form 355A (509)

ii.

NRC FORM 366A US. NUCLEAR REGULATORY (X)MMISSION APPROVED OMB NO;3'I500104 (64)9) i EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT IL'ER) INFORMATION COLLECTION REQUEST: 505) HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH IP4)30), U.S. NUCLEAR

'REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (3)500)04), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

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

YEAR SEQUENTIAL REVISION NVMSSA V&Ã NVMSEA Palo Verde Unit 2 TEXT //I IINYP sssso is PSII/)sd, oso sddirioos/NRC Fam 3554's/ (12) 05000529 8 8 015 0 3 oF 0 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't approximately 1015 MST on December 7, 1988. Additionally, the monitor was reset and operated properly. Thus, at approximately 1030 MST on December 7, 1988'U-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 the work request was, closed.

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 evaluati'on of a monitor's ability to perform its function. This revision is expected to be compl'ete by July 16, 1990'.

The training received by the performance group responsible for shiftly surveillance of the Radiation Monitoring System has been evaluated. Based on this evaluation, revision of the training program is not required.

NRC FoIm 366A (64)9)

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NRC FORM SSEA U.S. NUCLEAR REGULATORY COMMISSION (64) 9) APPROVED 0MB NO. 31500104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION REOUESTI 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P430). U.S.'NUCLEAR REGULATORY COMMISSION. WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT '(3)504)104). OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITYNAME (11, DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR PN SEQUENTIAL NUMSER REVISION NUMBER Palo Verde Unit 2 0 5 0 0 0 5 2 9 8 8015 03 07 QF 0, 7 TEXT lllrr>>rE Sr>>ct lI rrr)rrrrrd,'rl~ EddII4Ir>>l IVRC Fe m 3N43) (17)

IV. PREVIOUS SIMILAR EVENTS:

There have been no previous similar events reported pursuant to 10CFR50.73.

NRC Form 366A (64)9)

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