ML17311A370

LER 94-003-00:on 940927,startup Channel High Neutron Flux Alarm Declared Inoperable.Caused by Personnel Error. Personnel counseled.W/941021 Ltr

ML17311A370
Person / Time
Site:	Palo Verde
Issue date:	10/21/1994
From:	Grabo B, James M. Levine ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
192-00909-JML-B, 192-909-JML-B, LER-94-003-02, LER-94-3-2, NUDOCS 9411020248
Download: ML17311A370 (11)

Text

REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION 'iVBR:9411020248 DOC.DATE: 94/10/21 NOTARIZED: NO DOCKET N FACIL:STN-50-529 Palo Verde Nuclear Station, Unit 2, Arizona Publi 05000529 AUTH. NAME AUTHOR AFFILIATION GRABO,B.A. 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 94-003-00:on 940927,startup channel high neutron flux

=-

alarm inoperable. Caused by personnel error.CRS & reactor operator will received counseling.W/941021 DISTRIBUTION CODE: IE22T COPIES RECEIVED: LTR TITLE: 50.73/50.9 Licensee Event Report (LER),

NOTES:Standardized plant.

l ltr.

ENCL I SIZE:

Incident Rpt, etc.

~

05000529 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD4-2 PD 1 1 HOLIAN, B 1 1 TRAN,L 1 1 INTERNAL: ACRS 1 1 AFODJFROQB/DS P 2 2 AEOD/SPD/RRAB 1 1 ~FILE CENTER 02 1 1 NRR/DE/EELB 1 1 NRR/DE/EMEB 1 1 NRR/DORS/OEAB NRR/DRCH/HICB NRR/DRSS/PRPB 1,1 1

2 1

2 NRR/DRCH/HHFB, NRR/DRCH/HOLB NRR/DSSA/SPLB 1

1 1

1 1

1 NRR/DSSA/SRXB 1 1 NRR/PMAS/IRCB-E 1 1 RES/DSIR/EIB 1 1 RGN4 FILE 01 1 1 EXTERNAL: L ST LOBBY WARD 1 1 LITCO BRYCE,J H 2 2 NOAC MURPHY,G.A NRC PDR 1, 1 1 1

NOAC POORE,W.

NUDOCS FULL TXT 1

1 1

1 YO1'E TO ALL"RIDS" RECIPIENTS:

PLEASE IIELP L:S TO REDUCE O':KSTE! CONTACT'I'IIE DOCL'XfENTCONTROL DESk, ROOXf Pl-37 (FXT. 5%-~OS' 'I 0 I:.LIXIIYATE5'OL'R XA! f L P!IOXI DISTRI8L" I'ION LIS'I'S I'OR DOCI 'Xfl i'I'S YOL')Oi"IIII'.I)!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 28 ENCL 28

h i

Arizona Public Service Company PALO VERDE NUCLEAR GENERATING STATION P.O. BOX 52034 ~ PHOENIX. ARIZONA 85072-2034 192-00909-JMUBAG/KR JAMES M. LEVINE October 21, 1994 VICE PRESIDENT NUCLEAR PRODUCTION U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Mail Station P1-37 Washington, D.C. 20555

'ear Sirs:

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

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

Licensee Event Report 94-003-00 File: 94-020-404 Attached please find Licensee Event Report (LER) 94-003-00 prepared and submitted pursuant to 10CFR50.73. This LER reports a missed Technical Specification Limiting Condition for Operation ACTION requirement for monitoring reactor coolant system boron concentration with one startup channel high neutron flux alarm inoperable.

In accordance with 10CFR50.73(d), a copy of this LER is being forwarded to the Regional Administrator, NRC Region IV. If you have any questions, please contact Burton A. Grabo, Section Leader, Nuclear Regulatory Affairs, at (602) 393-6492.

Sincerely, JML/BAG/KR/pv Attachment cc: L. J. Callan (all with attachment)

K. E. Perkins K. E. Johnston INPO Records Center 9411020248 941021 PDR ADOCK 05000529 8 PDR

I[

II' l'

~ LICENSEE EVENT REPORT (LPr ACIUTY NAME (1) DOCKET NUMBER (2) PAGE (3)

Palo Verde Unit 2 0 5 0 0 0 5 2 9 1 oF0 4 (e)

Missed TS LCO ACTION for Monitorin Reactor Coolant S stem Boron Concentration EVENT DATE 5 LER NUMBER REPORT DATE OTHER FACIUTIES INVOLVED 8 MONTH DAY YEAR SEQUENTIAL NUMBERS NUMBER NUMBER 0 5 0 0 0 0 9 2 7 9 4 9 4 0 0 3 - 0 0 1 0 2194 IS REPORT IS SUBMIITEDPURSUANT TO THE REOUIREMENTB OF 10 CFR C (Chertr one or more ot the torlowin0) (11) 0 5 0 0 0 20.4Q(b) 20.45(c) SL73(aX2)(n) 73.71(b) 20.45(a) (1)(i) 5035(c)(1) 5073(a)(2)M 73.71(c) lEVEL(10) 20.45(a)(1)(ii) 50.35(c)(2) 5(L73(a)(2)0t0 OTHER (Specity in Ababeci 20.45(a)(1)(iii) 50.73(a)(2mi IL73(alRbÃA) bMow and In TroL NRC Form 20.45(a)(1)(h) 5(L73(a)(2)(a) 50.73(a)(2)(VI)(B) 20.45(a)(1)(r) 50.73(a)(2)(ia) 9173(a)(2)00 UCENSEE coNTAOT FoR TIes LER (1 2)

Burton A. Grabo, Section Leader, Nuclear Regulatory Affairs 60 2 3 9 3 - 64 2 COMPLETE ONE UNE FOR EACH COMPOtiENT FAILURE DESCRIED IH TteS REPORT (13)

MANUFAC. REPORTABLE TURER TO NPRDS SUPPLEMENTAL REPORT EXPECTED (1e) EXPECTED SUBIASSON DATE (15)

On September 27, 1994, at approximately 1952 MST, Palo Verde Unit 2 was in Mode 5 (COLD SHUTDOWN), when the oncoming night shift Control Room personnel determined that the performance of the TS LCO 3.1 2.7 ACTION statement was ~

required with one startup channel high neutron flux alarm inoperable and that it had been missed by the day shift Control Room personnel. TS LCO 3.1.2.7 ACTION a.l states that at the time the alarm is determined to be inoperable and at subsequent applicable monitoring frequencies (i.e., every two hours),

the reactor coolant system (RCS) boron concentration shall be determined by either boronometer or RCS sampling. The appropriate surveillance procedure was subsequently performed to comply with the TS LCO 3.1.2.7 ACTION statement.

An investigation of the event determined that the cause of the missed TS LCO ACTION requirement was attributed to personnel error by Control Room personnel. The Control Room personnel received appropriate counseling.

There have been no previous similar events reported pursuant to 10CFR50.73 in the last three years."

LICk EEEVENTREPORT(LER)TEXTCON UATION LER NUMBER TEAR SEQVEtK4AL REHSON NNlBER NURSER Palo Verde Unit 2 0 5 0 0 0 5 2 9 9 4 - 0 0 3 - 0 0 0 20F 0 4 REPORTING REQUIREMENT:

This LER 529/94-003-00 is being written to report an event that resulted in a condition prohibited by the plant's Technical Specifications (TS) as specified in 10. CFR 50.73(a)(2)(i)(B).

Specifically, between the hours of 0854 MST and 1630 MST on September 27, 1994, Palo Verde Unit 2 was in Mode 5 (COLD SHUTDOWN) with one startup channel high neutron flux alarm (IG) inoperable when the ACTION requirements of TS Limiting Condition for Operation (LCO) 3.1.2.7 BORON DILUTION ALARMS (IG) were not performed. TS LCO 3.1.2.7 ACTION a.l states that at the time the alarm is determined to be inoperable and at subsequent applicable monitoring frequencies (i.e., every two hours),

the reactor coolant system (RCS) (AB) boron'oncentration shall be determined by either boronometer or RCS sampling.

Unit 2 was in a scheduled Mid-Cycle outage with the RCS at approximately 98 degrees Fahrenheit and at atmospheric pressure.

2. EVENT DESCRIPTION:

On the morning of September 27, 1994, Instrumentation and Control personnel (utility, non-licensed) requested permission from Control Room personnel (utility, licensed) to calibrate the excore startup channel drawers. Prior to declaring startup channel 1 high neutron flux alarm inoperable, the Control Room Supervisor (CRS) reviewed the applicable TS LCO 3.1.2.7, veri, fied the current RCS boron concentration with the boronometer and the most recent RCS sample, and verified that the startup channel 2 alarm was operable. In addition, a reactor operator performed the shiftly surveillance requirement for startup channel and boron dilution alarm channel checks. The startup channel 1 high neutron flux alarm was declared inoperable and TS LCO 3.1.2.7 ACTION a was entered at approximately 0854 MST. Following completion of the calibration, a channel check was performed and startup channel 1 high neutron flux alarm was declared operable and TS LCO 3.1.2.7 ACTION a was exited at approximately 1630 MST.

At approximately 1952 MST, following shift turnover and a review of day shift activities, the oncoming night shift Control Room personnel determined that the performance of the TS LCO 3.1.2.7 ACTION statement was required with one startup channel high neutron flux alarm inoperable and that it had been missed by the day shift Control Room personnel.

The appropriate surveillance procedure was subsequently performed to comply with the TS LCO 3.1.2.7 ACTION statement.

0 t

LICE ~ EE EVENT REPORT(LER) TEXT CON i UATION FACIUTY NAME DOCKET NUMBER LER NUMSER PAOE RECON NUMBER Palo Verde Unit 2 0 5 0 0 0 5 2 9 9 4 - 0 0 3 - 0 0'0 3 QF0 4

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

Following the discovery of the event, Control Room personnel verified, per the boronometer trend recorder, that the boron concentration had not changed during the period that the startup channel 1 high neutron flux alarm had been inoperable (i.e., no dilution event was identified).

Therefore, there were no safety consequences or implications as a result of this event. This event did not adversely affect the safe operation of the plant or health and safety of the public.

4, CAUSE OF THE EVENT:

An independent investigation of this event was conducted in accordance with the APS Incident Investigation Program. As part of the investigation, a human performance evaluation was performed. The evaluation determined that the primary causal factor was inappropriate work practices in that the CRS reviewed the TS LCO 3.1.2.7 but did not identify nor perform the appropriate TS LCO ACTION requirements (SALP Cause Code A: Personnel Error). In addition, the reactor operator who performed the shiftly surveillance requirement for startup channel and boron dilution alarm channel checks did not refer to the complete surveillance procedure but only used the data sheets available in the shiftly surveillance package. The complete surveillance procedure included guidance to perform the appropriate boron concentration monitoring if a startup channel or boron dilution alarm is inoperable.

No unusual characteristics of the work location (e.g., noise, heat, poor lighting) directly contributed to this event. There were no procedural errors which contributed to this event.

5. STRUCTURES, SYSTEMS, OR COMPONENTS INFORMATION:

The startup channel high neutron flux alarm was declared inoperable to perform channel calibrations. No other structures, systems, or, components were inoperable at the start of the event which contributed to this event. No component or system failures were involved, No failures of components with multiple functions were involved. No failures that rendered a train of a safety system inoperable were involved. There were no safety system responses and none were necessary.

T CORRECTIVE ACTIONS TO PREVENT RECURRENCE:

A night order was issued in Units 1, 2, and 3 reinforcing the expectation that the entire procedure be used when performing the shiftly surveillance requirements with data sheets. The human performance evaluation determined that the incomplete review of required TS LCO ACTIONs by the CRS was an isolated case of personnel error. The CRS and reactor operator received appropriate counseling.

N LICENSEE EVENT REPORT (LER) TEXT CONTINUATION PACLITY NAME DOCKET NUMBER LER NUMBER PAGE SEQUENCIAI. REVISOH NUMBER NUMBER Palo Verde Unit 2 0 5 0 0 0 5 2 9 9 4 - 0 0 3 - 0 0 0 40F 0 4

7. PREVIOUS SIMILAR EVENTS:

Although previous similar events involving inappropriate work practices by Control Room personnel have-been reported, no events have been reported pursuant to 10CFR50.73 which involved the same cause and sequence of events. The human performance evaluation determined that the incomplete review of required TS LCO ACTIONs by the CRS was an isolated case of personnel error. Therefore, the corrective actions for any previous event would not have prevented this event.

1 S'

h t

II l

1