ML18093A722

LER 88-003-00:on 880208,Tech Spec Table 3.3-12 Action 27 Not Complied With.Caused by Personnel Error Associated W/ Inadequate Communications & Training.Operations Dept Mgt Reviewed Event & Procedures Will Be modified.W/880309 Ltr

ML18093A722
Person / Time
Site:	Salem
Issue date:	03/09/1988
From:	Pollack M, Zupko J Public Service Enterprise Group
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
LER-88-003, LER-88-3, NUDOCS 8803170275
Download: ML18093A722 (6)

Text

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M. J. Pollack - LER Coordinator CCIWLETll ONI LINI 'Oii EACH COWONl!NT l'AILUlll! Dl!IClllHD IN THll lllPOllT 11:11 CAUSE SYSTEM COMl'ONENT MANUFAC- SYSTEM MANUFAC-TURER COMl'ONENT TUREii I I I I I I I I I I I I I I I I I I I I I I I I I I I I l l l l l l l l l ili l i l i!il lil l l l~l l!l IUPPLllllNTAL REPOllT l!XPICTID (141 MONTH DAY Yl!AR rx, EXPECTED n YES (If l'tf, ,,_,,.,.,. EX,.ECTED SIJ*MISSIDN DATE) NO SUIM1$110N DATE 1151 I I I On 2/08/88, it was identified that Radiation Monitoring System Channel (RMS} 2R19C {_IL} was inoperable since 02/02/88 and the required periodic samples were not taken. This is contrary to the requirements of Technical Specification Table 3.3-12 Action 27. On 02/01/88 at 1245 hours0.0144 days <br />0.346 hours <br />0.00206 weeks <br />4.737225e-4 months <br />, during preventive maintenance of the 2R19C Steam Generator Blowdown sample line pressure regulators, flow through the sample line stopped due to the failure of the low pressure regulator. Upon initiation of the preventive maintenance, Technical Specification Table 3.3-12 Action 27 was entered to support replacement of the malfunctioning high pressure r~gulator. On 02/02/88 at 0100 hours0.00116 days <br />0.0278 hours <br />1.653439e-4 weeks <br />3.805e-5 months <br />, Shift Supervision exited the Action Statement after satisfactory completion of a 2Rl9C channel check. The on-duty shift was not aware of the flow problem when they exited the Action Statement. The root cause of this event has been attributed to personnel error associated with inadequate communications and training. Corrective action associated with this event includes: a discussion of this event by Maintenance management with maintenance personnel at "workshop" type sessions; Operations management have reviewed this event and have discussed it with the Shift Supervision involved; a review of this event for incorporation into applicable training programs; modification of procedures to address monitoring S/G Blowdown sample line flow; and an investigation to determine the need for providing R19 sample flow indication/alarm in the Control Room.

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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 2 5000311 88-003-00 2 of 5 PLANT AND SYSTEM IDENTIFICATION:

Westinghouse - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes are identified in the text as {xx:f IDENTIFICATION OF OCCURRENCE:

Technical Specification Table 3.3-12 Action 27 Not Complied With Discovery Date: 02/08/88 Report Date: 03/09/88 This report was initiated by Incident Report No.88-043.

CONDITIONS PRIOR TO OCCURRENCE:

Mode 1 Reactor Power 100% - Unit Load 1150 MWe DESCRIPTION OF OCCURRENCE:

On February 08, 1988, it was identified that Radiation Monitoring System Channel (RMS) 2R19C {ILi was inoperable since February 02, 1988 and the required periodic samples were not taken. This is contrary to the requirements of Technical SpeGification Table 3.3-12 Action 27.

Technical Specification 3.3.3.8 states:

"The radioactive liquid effluent monitoring instrumentation channels shown in Table 3.*3-12 shall be OPERABLE with their alarm/trip setpoints set to ensure that the limits of Specification 3.11.1.1 are not exceeded. The alarm/trip setpoints of these channels shall be determined in accordance with the OFFSITE DOSE CALCULATION MANUAL (ODCM)."

Technical Specification Table 3.3-12 Action 27 states:

"With the number.of channels OPERABLE less than required by the Minimum Channels OPERABLE requirement, effluent releases via this pathway may continue provided grab samples are analyzed for gross radioactivity (beta or gamma) at a limit of detection of at least 10- 7 microcuries/gram:

a. At least once per 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> when the specific activity of the secondary coolant is greater than 0.01 microcuries/gram DOSE EQUIVALENT I-131.

b. At least once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> when the specific activity of the secondary coolant is less than or equal to 0.01 microcuries/gram DOSE EQUIVALENT I-131."

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NVMBER LER NUMBER PAGE Unit 2 5000311 88-003-00 3 of 5 DESCRIPTION OF OCCURRENCE: (cont'd)

On February_l, 1988 at 1245 hours0.0144 days <br />0.346 hours <br />0.00206 weeks <br />4.737225e-4 months <br />, during preventive maintenance of the 2R19C Steam Generator Blowdown sample line pressure regulators, flow through the sample line stopped due to the failure of the low pressure regulator. Upon initiation of the preventive maintenance, Technical Specification Table 3.3-12 Action 27 had been entered to support replacement of the malfunctioning high pressure regulator.

On February 2, 1988 at 0100 hours0.00116 days <br />0.0278 hours <br />1.653439e-4 weeks <br />3.805e-5 months <br />, Shift Supervision exited the Action Statement after satisfactory completion of a 2R19C channel check, which is an electrical check of the detection circuit. The on-duty shift was not aware of the flow problem when they exited the Action Statement.

On February 8, 1988, the maintenance technician responsible for the R19C preventive maintenance work order questioned the shift if the Unit was still in the Action Statement. Upon recognizing that the Unit should be in the Action Statement, it was re-entered and periodic

~ampling was initiated. On February 19, 1988 at 1857 hours0.0215 days <br />0.516 hours <br />0.00307 weeks <br />7.065885e-4 months <br />, repair of the low pressure regulator was completed, sample line flow was verified, and the Action Statement was exited.

APPARENT CAUSE OF OCCURRENCE:

The root cause of this event has been attributed to personnel error associated with inadequate communications and training.

On February 1, 1988 a Maintenance-I&C technician was assigned to replace a malfunctioning high pressure regulator on the 2R19C sample line. This regulator was found malfunctioning on January 29, 1988 during preventive maintenance. The preventive maintenance was being performed in accordance with procedure IC-1.4.003, "General Instrument and Control Procedure - General Instrument Calibration Procedure for Field Devices". This is a generic procedure providing the guidelines for instrument calibrations.

Prior to regulator replacement, the technician requested Operations to place the 2R19C channel in "block" thereby preventing any spurious signals, generated during the regulator replacement, which could result in blowdown isolation. The shift supervisor made a log entry of the Techiiical Specification Action Statement entry.

In addition to replacing the high pressure regulator the technician checked the in-line low pressure regulator in accordance with the original Work Order job scope. The low pressure regulator failed stopping flow through the sample line. This was indicated by an in-line pressure gauge downstream of the low pressure regulator. The technician did not find his supervisor immediately. However, the technician did go to the on-coming shift supervisor and informed him, "the channel functions electrically but there is no flow". This was not a **clear communication. The next day, this same technician was assigned an "A" prio~ity work order and he subsequently neglec~ed to inform his supervisor of the low pressure regulator condition.

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 2 5000311 88-003-00 4 of 5 APPARENT CAUSE OF- OCCURRENCE: (cont'd)

The shift supervisor did not make a log entry of the no flow condition nor did he identify the condition to the on-coming shift in his shift turnover. Also, since the Maintenance-I&C Supervisor was not aware of the inoperable low pressure regulator with the subsequent "no flow" sample line condition, the supervisor did not complete an Incident Report (IR). An IR is required to be initiated whenever Technical Specification related equipment is found inoperable, as per Administrative Procedure AP-6, "Incident Report/Licensee Event Report Program".

On February 2, 1988, Shift Super~ision exited the Action Statement after satisfactory completion of a 2R19C channel check and a review of the Managed Maintenance Information System (MMIS) (a computerized work order system) for outstanding work orders against the 2R19C monitor.

The review did not reveal the current status of the 2Rl9C low pressure regulator. -Shift Supervision did not question if adequate flow to the detector was available. The shift did not realize the R19 detectors could appear to be operable without sample flow to the detector. The Technic~l Specification surveillance criteria addresses the electrical functioning of the detector but not sample flow to the detector.

Shift Supervision was not aware the preventive maintenance work order was not closed and flow was prevented from going to the detector due to the failed low pressure regulator. Had an Incident Report been initiated by Maintenance-I&C or a shift log entry been made addressing the "no flow" condition, the shift would have been aware of the necessity of remaining in the Action Statement.

ANALYSIS OF OCCURRENCE:

The 2Rl9C RMS channel is used to monitor No. 23 Steam Generator Blowdown to ensure an unidentified radioactive release does not occur. If radioactivity were identified, blowdown isolation would occur automatically.

The preventive maintenance of the R19 channels included ensuring proper operation of the high and low pressure regulators which in turn ensure adequate flow through the sample line. As stated in the Description of Occurrence Section, the low pressure regulator had failed preventing flow through the sample line.

During the period when the 2Rl~C channel was inoperable the 2R15, 2R46C and 2R40 RMS channels were operable. The 2R15 channel monitors the discharge from the condenser air removal exhaust header. The 2R46C channel monitors the No. 23 Steam Generator main steam line header in order to detect radioactivity indicative of a primary to secondary leak. The 2R40 RMS channel monitors the filtrate from the Steam Generator Blowdown Tank, for radioactivity, prior to processing in the Condensate Polisher. No significant increase in a~tivity was detected by these channels. Therefore, the health and safety of the general public was not affected. However, this event is reportable in accordance with Nuclear Regulatory Commission Code of Federal Regulations 10CFR 50.73(a) (2) (i) (B).

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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 2 5000311 88-003-00 5 of 5 CORRECTIVE ACTION:

This event has been reviewed by Maintenance management. The issues involved with this event have been discussed with Maintenance Department personnel in "workshop" type sessions. Stressed at these sessions was the need for clear and timely communication when performing a turnover with peers or supervision.

Operations Department management have reviewed this event and have discussed it with the Shift Supervision involved.

This event wili be reviewed by the PSE&G Nuclear Training Center and incorporated into applicable training programs.

Procedures will be modified to address monitoring S/G Blowdown sample line flow.

PSE&G Engineering will investigate the need for providing R19 sample flow indication/alarm in the Control Room.

MJP:pc SORC Mtg. 8S-020.

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OPS~G Public Service Electric and Gas Company P.O. Box E Hancocks Bridge, New Jersey 08038 Salem Generating Station March 9, 1988 U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555

Dear*Sir:

SALEM GENERATING STATION LICENSE NO. DPR-75 DOCKET NO. 50-311 UNIT NO. 2 LICENSEE EVENT REPORT 88-003-00 This Licensee Event Report is being submitted pursuant to the requirements of Nuclear Regulatory Commission requirements 10CFR 50.73(a) (2) (i) (B). This report is required within thirty days of discovery.

Sincerely yours,

~*lt:

General Manager-Salem Operations Jr.

MJP:pc Distribution The Energy People

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