ML17305A948

LER 90-009-00:on 900620,identified That License Holders Had Not Received Biennial Medical re-exams,per 10CFR55.21.Caused by Inadequate Tracking Sys & Medical Personnel Failure to Follow Procedures.Procedures developed.W/900719 Ltr

ML17305A948
Person / Time
Site:	Palo Verde
Issue date:	07/20/1990
From:	Bradish T, James M. Levine ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
192-00680-JML-T, 192-680-JML-T, LER-90-009, LER-90-9, NUDOCS 9007240200
Download: ML17305A948 (16)

Text

ACCELERATED D'RIBUTION DEMONSTTION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR: 9007240200 DOC. DATE: 90/07/20 NOTARIZED: NO DOCKET FACIL:STN-50-528 Palo Verde Nuclear Station, Unit 1, Arizona Publi, 05000528 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:

requirement for operator license.'/9 LER 90-009-00:on 900620,failure to satisfy medical DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:

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

NOTES' 05000528 RECIPIENT COPIES RECIPIENT COPIES D ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD5 LA 1 1 PD5 PD 1 1 D PETERSON,S. 1 1 CHAN,T 1 1 INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DS P/TPAB 1 1 AEOD/ROAB/DS P 2 2 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 RR PLB8D1 1 1 NRR/DST/SRXB 8E 1 1 REG FILE 02 1 1 RES/DSIR/EIB 1 1 ILE 01 1 1 EXTERNAL EGGG BRYCE i J ~ H 3 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 D

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 FROiv1 DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 36 ENCL 36

t4 Public Service Company PALO VERDE NUCLEAR GENERATING STATION P OBOX 52034 ~ PHOENIX, ARLZONA85072-2034 PRODUCTION'rizona JAMES I/I.

192-00680-JML/TRB/KR LEVINE'ICE PRESIDENT July 19, 1990 IIUCI.E4R U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555

Dear Sirs:

Subj ect: Palo Verde Nuclear Generating Station (PVNGS)

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

Licensee Event Report 90-009-00 File'0-020-404 Attached please find Licensee Event Report (LER) No. 90-009-00 prepared and submitted pursuant to 10CFR50.73. In accordance with 10CFR50.73(d), we are herewith forwarding a copy of the LER t'o 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/KR/dmn Attachment CC: W. F. Conway with attachment)

J. B. Martin D. H. Coe T. L. Chan A. C. Gehr Center'all A. H. Gutterman INPO Records

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l NRC FORM 38sl U.S. NUCLEAR REGULATORY COMMISSION (64)9) APPROVED OMB NO, 31500104 EXPIRES: 4l30i92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD LICENSEE EVENT REPORT (LER) COMMENTS AEGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (F630), U.S. NUCLEAR REGVLATORY COMMISSION. WASHINGTON. DC 20555.'AND TO THE PAPERWORK REDUCTION PROJECT (31500104). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (II DOCKET NUMBER 12) PA E 3 Palo Verde Unit TITLE I4) l 0 5 0 0 0 5 2 1 OF 06 Failure to Satisf Medical Re uirement For 0 eratorts License EVENT DATE (5) LER NUMBER (6) REPOAT DATE (7) O'THER FACILITIES INVOLVED (SI MONTH YEAR mvOL SEQVENTSAL FACILITYNAMES DOCKFT NUMBER(5)

DAY YEAR '(~. i N UM 8 8 A ".Fvrh<

rSUMBEle MONTH DAY YEAR Palo Verde Unit 2 0 5 0 0 0 5 2 9 06 20 9 0 9 0 0 0 9 000 7 0 p Palo Verde Unit 3 o so o o530 OPERATING THIS REPORT Is SUBMITTED PUASUANT TO THE REQUIREMENTS OF 10 cFR (): JChech one or more ol rhe lollow'npl (11)

MODE (9) 20.402(o) 20.405(cl 50.73( ~ ) (2)(iv) 73.71(h)

POWER 20.405 (e I (1((il 50.38(c) III 60.73( ~ I I 2) (v) 73.71(cl LEVEL p p 20.405 (e) (1)(ill 50.38(c) (2) 50.73( ~ )(2)(v)I) OTHER (SpecRy In Aostrect Oelow end in Text. iYRC Form 20.405( ~ ) (1)(i(I) 50.73( ~ I (2) li) 60.73(e) (2)(xiii)(AI 368A) 20A05 (e) (I I(iv) 50.73( ~ ) (2) (El 50,73(e)(2)(xiii) IS) 20.405( ~ l(1)(v) 60.73( ~ l(2) (ii)l 50.73( ~ )(2)lx)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER AREA CODE T. R. Bradish, Compliance Manager 60 23 93 -2 52 l COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS JIEPORT (13)

MANUFAC. EPORTABLE MANVFAC. EPORTABI.E CAUSE SYST EM COIISPONENT TVREA TO NPRDS CAUSE SYSTEM COMPONENT TURER TO NPRDS Q%%g',.Nih)

M@M'UPPLEMENTAL REPORT EXPECTED 114) MONTH DAY YEAR EXPECTED SUBMISSION DATE (15)

YEs illyn, compine ExpEcTED $ UBhrlsslDIY DATE) X NO ABSTRACT (Limit to lc00 sprees, le., epproximeteiy lilteen sinpre spore rypewrirren linn/ (181 On June 20, 1990, at approximately 1530 MST, Palo Verde Unit 1 was in Mode 3 (HOT STANDBY), Palo Verde Unie 2 was in Mode 5 (COLD SHUTDOWN), and Palo Verde Unit 3 was in Mode 1 (POWER OPERATION) when review of the reactor operator license holders'iennial medical examination documentation identified that several license holders had not received biennial medical reexaminations in accordance with 10CFR55.21 and some medical examinations did not exactly follow the guidance contained in ANSI/ANS-3 '-1983, "Medical Cereification and Monitoring of Personnel Requiring Operator Licenses for Nuclear Power Plants."

The root cause of the event is that an adequate tracking system for reactor operator biennial medical reexaminaeion did not exise. In addition, Medical Department personnel performing medical examinations did noe exactly follow ehe guidance of ANSI/ANS-3.4-1983. As corrective action, the affeceed reactor operators were removed from licensed activities and received medical reexaminations prior to resuming licensed activities. Also, administrative procedures are being developed eo delineate the requirements necessary in order eo fully comply with 10CFR55.21 and 55.25.

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

NRC Form 388 (84)91

NRC FORM 366A US. NUCLEAR REGULATORY COMMISSION (669) APPROVEO 0MB NO. 31500104 EXPIRES: 4/30/92 LICENSEE EVENT REPORT ILER) ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REOUESTI 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 (31500(04), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON. DC 20503.

FACILITYNAME (II DOCKET NUMBER (2)

LER NUMBER (6) PAGE (3) yEAR Sg+$ SCOVENTIAL 46VISIQN NVMOS4 NVMOO4 Palo Verde Unit 1 o s o o o 5 2 8 9 0 0 0 9 0 0 0 2oFO 6 TEXT /I!more space is rotor/tr/ ost addrr'one//VRC Form 366A's/ (ll)

I. DESCRIPTION OF WHAT OCCURRED:

Inieial Conditions:

On June 20, 1990, at approximately 1530 MST, Palo Verde Unit 1 was in Mode 3 (HOT STANDBY) at normal operating temperature and pressure; Palo Verde Unit 2 was in Mode 5 (COLD SHUTDOWN) with Reactor Coolant Systein (RCS)(AB) at approximately 145 degrees .

Fahrenheit and approximately 95 pounds per square inch-absolute, and Palo Verde Unie 3 was in Mode 1 (POWER OPERATION) at approximately 100 percent power.

Reporeable Evene Description (Including Dates and Approximate Times of Major Occurrences):

Event Classification: Condieion prohibited by the PVNGS Technical Specificaeion Section 6.0, "Administraeive Controls."

On June 20, 1990, a review of the reactor operator license holders'iennial medical examination documentation identified thae several license holders (ueility, licensed) had not received biennial medical reexaminations in accordance with 10CFR55.21 and some medical examinations did noe exactly follow the guidance contained in ANSI/ANS-3.4-1983, "Medical Certification and Monitoring of Personnel Requiring Operator Licenses for Nuclear Power Plants." Subsequently, an independent investigation of this event was conduceed in accordance with the PVNGS Incident Inveseigation Program. As part of the investigation, the Medical Department personnel (utility, non-licensed) reviewed each current license holder's medical file back to 1987 to ensure that 'each license holder had received a medical examination conforming to the regulations in 10 CFR55.21, 55.23, and 55.27: The results of the investigation were as follows:

Thirty-nine (39) license holders, who were determined to have current medical examinations, were found eo have not been in conformance with 10CFR55.21 [i.e, the interval

'etween previous medical examinations exceeded the two year (biennial) requirement) ae some time since 1987.

Nine (9) license holders'ere found not to be in-conformance with 10CFR55.21 as they had exceeded the two year. (biennial) medical examination requirement.

Six'6) Iiconse holders, who were determined to have current medical examinations, were found to have not been in NRC Form 366A (669(

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NRC FORM 356A VS, NUCLEAR REGULATORY COMMISSION (669) APPROVED OMB NO.31504)104 E XP I R E S'/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILERI INFORMATION COLLECTION REQUEST: 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (PJ)30). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

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

SEQUENTIAL PrS. REVISION YEAR gP N U rso E R ~~ NUUSER Palo Verde Unit 1 o s o o o 5 2 8 9 0 0 0 9 0 0 0 30FO 6 TEXT /I/ mort spsst /s rsOIr/rtd. oss sddr)/orrs/ AIRC Form 35r/A'4/ ((7) 4 conformance with 10CFR55.33 upon initial license issuance.

The medical examinations conducted as part of their initial application were found to be incomplete as they did not include all requirements of ANSI/ANS-3.4-1983.

Two (2) licensed holders were found not to be in conformance with 10CFR55.33 as they did not have a currently valid medical examination and were not yet due to receive their

...first biennial medical examination following license issuance. The medical examinations conducted as part of their initial application were found to be incomplete as they did not include all requirements of ANSI/ANS-3.4-1983.

One (1) license holder did not meet the requirements of 10CFR55.33(a)(1).

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

Not applicable - no structures, systems, or components were inoperable at the start of the event which contributed to this event.

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

Not applicable - no component or system failures were involved.

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

Not applicable - no component failures'were involved.

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

Not applicable - no component failures were involved.

For a failure that rendered a train of a safety system inopeiable, 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.

NRC Form 366A (64)9)

I I

NRC FORM 365A U.S. NUCLEAR REGULATORY COMMISSION (6J)9) APPROV EO OMB NO, 31500(ot EXPIRES: 4130(92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: SOD HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH IPJ(30). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (3)50010(>. OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, OC 20503.

FACILITY NAME (I) DOCKET NUMBER (2) I.ER NUMBER (6) PAGE (3)

YEAR ss2rs scovsNTIAL lSPP A(vl5lorr NVMSSA AX NUMttt Palo Verde Unit 1 o 6 o o o 5 2 8 90 009 00 0 4DF 0 6 TEXT lllmort sptst ls rtrrrdrtd, tst tddisitttl A'RC Form AM'sl (17)

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

Not applicable - there have been no component or system failures or procedural errors identified'.

Cause of event An independent investigation of this event has been conducted in accordance with the PVNGS Incident Investigation Program'. As part of the investigation, a determination of the cause of the event was performed. The investigation determined that the root causes are as follows:

No integrated program existed that assigned the responsibility or accountability (to a single person or group) to maintain license holders'edical requirements current. In addition, an adequate system did not exist to track the status of the license holders'iennial medical reexaminations. Therefore, forty-eight (48) license holders exceeded the two year medical examination requirement specified in 10CFR55.21 (SALP Cause Code D: Defective Procedures).

The Medical Department personnel performing the medical examinations did not exactly follow the guidance contained in ANSI/ANS-3.4-1983. The nurse (utility, non-licensed) believed that the APS physician (contractor, non-licensed) was able to waive certain portions of the medical examination. The physician was not familiar with the guidance provided in ANSI/ANS-3.4-1983 (SALP Cause Code A:

Personnel Error). Therefore, eight (8) license holders received incomplete initial medical examinations.

The APS physician was not familiar with the reporting requirements specified in 10CFR55.25 when the reactor operator notified the physician of a medical condition that may have caused the reactor operator to not meet the requirements of 10CFR55.21 (SALP Cause Code A).

No unusual characteristics of the work location (e.g., noise, heat, poor lighting) directly contributed to this event.

Safety System Response:

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

NRC Form 366A (669)

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NRC FORM 366A US. NUCLEAR REGULATORY COMMISSION 0

(649) APPROVED OMB NO.31500108 EXPIRES: O/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, WASHING'TON OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500)04). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503, I FACILITY NAME. 11) DOCKET NUMBER (2) LER NUMBER (6) PAGE (31 YEAR NM SeOVSNTIAL ~ o II1 V IS IO N Nits NVIaotN iN> NVMStrr Palo Verde Unit 1 p 5 p p p 5 2 8 9 0 0 0 9 0 0 05oFO 6 TEXT /I/ more spare /s reoor/ed, use addi(iona/HRC Form 366A's/ (12)

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

II. ASSESSMENT OF THE SAFETY CONSEQUENCES AND IMPLICATIONS OF THIS EVENT No adverse safety consequences or implications resulted from this event.

10CFR55.33(a)(l) states that the Commission will approve an initial application for a license, if it finds that the applicants "medical conditions and general health will not adversely affect the performance of assigned operator job duties or cause operational errors endangering public health and safety." PVNGS does not rely solely on the biennial medical examination to ensure that a license holder meets the r'equirements of 10CFR55.21. In accordance with the continual behavior observation program, the supervisor is responsible for monitoring the individuals who he or she supervise and for reporting to the Fitness for Duty Administrator any observations of behavior which indicates that a person may not be fit for duty for any reason (e.g., stress, fatigue, injury or illness). In addition, each employee at APS shall report to his or her immediate supervisor any instance of actual or suspected behavior which may indicate that a person is not fit for duty. As, required by the fitness for duty program, the one reactor operator undergoing treatment with a substance prescribed by a licensed physician reported this to his supervisor. The supervisor notified the Medical Department. At the time of notification, the APS physician did not believe that the reported condition would result in operator incapacitation. However, some restrictions (e.g., no stair climbing, no operation of power tools, no driving on site, and no working alone in the control room) were to be in effect for the duration of the medication. No unusual behavior has been reported in this time frame related to the license holders described in Section I.B. Thus, this event represents no impact to the health and safety of the public.

III. CORRECTIVE ACTION:

Immediate:

After identifying the license holders who were not administratively qualified, the Medical Department personnel immediately contacted the appropriate supervisors. Each of the affected license holders was restricted from performing licensed activities until the appropriate medical examination could be administered.

The Medical Department notified the Licensing Department of the reactor operator who did not meet the requirements of 10CFR55.21.

APS is preparing a report in accordance with 10CFR55.25 to notify NRC Form 366A (6J)9)

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