ML19332B619

LER 89-013-00:on 891003,RWCU Sys Valve 1G31-F020 Closed, Rendering Inservice Reactor Coolant Monitor Inoperable. Caused by Cognitive Personnel error.In-line Conductivity Surveillance Initiated & Personnel counseled.W/891031 Ltr

ML19332B619
Person / Time
Site:	Hatch
Issue date:	10/31/1989
From:	Hairston W, Tipps S GEORGIA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
HL-807, LER-89-013-02, LER-89-13-2, NUDOCS 8911090267
Download: ML19332B619 (6)

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-U.S'.' Nuclear Regulatory Commission  :

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PLANT HATCH - UNIT 1>

NRC DOCKET 50-321 m . OPERATING LICENSE DPR-57' LICENSEE EVENT REPORT PERSONNEL-ERROR 1RESULTS.IN ,

iMISSED TECHNICAL SPECIFICATION SURVEILLANCE Gentlemen:'

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.. :In accordance'with the requirements of 10 CFR 50.73(a)(2)(i), Georgia Power Company is . submitting the7 enclosed Licensee ' Event Report - (LER)

' concerning personnel E errorz which ' resulted in: the - inadequate ' performance of a Technical Specifications surveillance. .This event occurred'at' Plant 1 Hatch. . Unit 1 7 Sincerely.

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H. G. Hairston, III JKB/eb ,

Enclosure:

.LER 50-32_1/1989-13

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,. Mr. H. C. Nix,< General Manager - Nuclear Plant 7.' Mr. J. D.:Heidt,. Manager Nuclear Engineering and Licensing - Hatch <

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' U.S. Nuclear Reaulatorv Commission. Washinaton.- D.C.

Mr.'L.-P. Crockir, Licensing Project Managir - Hatch

.U.S. Nuclear Regulatory Commission. Reaion II Mr. S. D. Ebneter, Regional Administrator Mr -J..E. Henning Senior Resident Inspector - Hatch F

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On 10/03/89, at approximately 0305 CDT, Unit- One was in the Run mode at an approximate power level of 2433 CMWT (approximately 100 percent of rated thermal power). At that time, Reactor Water Cleanup (RWCU, EIIS Code CE)

I system valve 1G31-F020 was closed rendering the inservice reactor coolant continuous in-line conductivity monitor (EIIS Code KN) inoperable.

However, compensatory actions were not taken as required by Unit 1 1 Technical Specifications section 4.6.F.2 to ensure that reactor coolant

-conductivity was monitored on a continuous or periodic basis. The i

condition was identified at approximately 2315 CDT, on 10/03/89, at which time Limiting Condition for Operation (LCO) 1-89-468 was initiated to ensure that peric,dic analysis of the reactor coolant for conductivity was performed as required by the Technical Specifications.

The root cause of the event was cognitive personnel error. Licensed personnel- failed to recognize that closing of the valve rendered the conductivity monitor inoperable and that compensatory actions were required.

Corrective actions for the event included the initiation of an in-line conductivity surveillance as required by the Technical Specifications and will include the counseling of involved personnel.

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'as:(EIIS Code XX).

SUMMARY

OF' EVENT 10n 10/03/89c at approximately.0305 CDT, Unit 0ne was' in the Run mode. at Tan ~ approximate power level of 2433.CMWT- (approximately .100 percent of

-rated thermal = power). 'At that time, Reactor Water Cleanup-(RWCU, EIIS Code CE)isystem valve.1G31-F020 was closed rendering the-inservice.

. reactor. coolant continuous in-line' conductivity monitor: inoperable;

. However, compensatory actions 'were not.taken as required by Unit 1 (Technical: Specifications section 4.6.F.2 to ensure that reactor coolant conductivity was monitored on a continuous or periodic basis. . The condition was. identified'at approximately. 2315 CDT, on 10/03/89, at

.which time Limiting Condition for Operation (LCO) 1-89-468 was initiated sto- ensure that periodic. analysis of the reactor coola'n t for conductivity--

- was,perfermed as: required by the Technical Specifications.

The root 'cause of- the event-was cognitive personnel error. Licensed Lpersonnel failed' to _ recognize that closing of the valve rendered the conductivity l monitor-:inoperableTand- that' compensatory actions were required.

Corrective actions' for the event included the initiation of an in-line conductivity surveillance' as required by> the Technical Specifications and will-include' the counseling of involved. personnel.

DESCRIPTION'0F EVENT l

On .10/03/89,;at.approximately 0305 CDT, Unit 1 was in the Run mode at an i

' approximate power level' of'2433 CMWT (approximately 100 percent of rated

.thermalipower). At that time; a clearance was implemented to close RWCU

valve 1G31-F020 to support change-out of sample line- filter 1G31-D010A.

' Also at that time,~ the reactor coolant in-line continuous conductivity monitoring system was aligned to analyze reactor coolant via the RWCU

system.- Closing, valve lG31-F020 resulted in isolating flow to the

. monitoring system. Reactor coolant was then no longer being analyzed

- s _foriconductivity on a continuous basis. The licensed shift supervisor

. responsible .for issuing.the clearance did not realize this and, thus,

? failed to take compensatory actions as required by Unit 1 Technical Specifications section 4.6.F.2. The specification requires that reactor T . coolant' be monitored continuously for conductivity and that whenever the l continuous monitoring system is inoperable, an in-line conductivity

. measurement.be obtained every four hours when reactor coolant is greater than 212 F.

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0l 0 Oj 3 or 0l5 rixt a A nac r asuwnn L . Consequently. at 'the time' the valve was closed, the reactor coolant was

. not being monitored continuously for conductivity and the four-hour e- , surveillance was not initiated.

tat' approximately 1800~ CDT on.10/03/89, a once per shift channel check on cs , the reactor coolant conductivity recorder was performed as required by

% 34SV-SUV-019-2S, " Surveillance Checks."~ However, isolating' ficw to the conductivity element-did not produce a sufficient change to the reading n

on the recorder such that the-channel check would enable identification

of the condition. Although conductivity readings normally would be expected 'to rise in the presence of stagnant water, other operational

. parameters can also influence conductivity readings at low levels.

. At approximately -2315 CDT, on .10/03/89, an RWCU system isolation-occurred on system high- differential flow.- (This event was reported in LER 50-321/1989-012). At that-time, licensed personnel, realizing that a RWCU. isolation would prevent flow to the RWCU input of the reactor Ecoolant conductivity monitor, directed chemistry personnel to transfer the conductivity system -to the Recirculation system (EIIS Code AD) input. Upon transferring the system, it was determined that- the conductivity monitor associated with the Recirculation input (lP33-N012) wasl not operating properly. Consequently, at approximately 2315 CDT, the-in-line continuous conductivity monitoring-system was declared inoperable and the four hour conductivity surveillance required by the Technical L Specifications was initiated. Limiting Condition for

~ 0peration; (LCO) 1-89-468 was issued to track the surveillance.

_ .During the investigation of the inoperable conductivity monitor, 1P33-N012, it was determined that the 1G31-F020 valve had been closed rendering conductivity monitor 1G31-N009 inoperable without any

.. compensatory action being taken. Deficiency Card 1-89-4078 was written

' to document the condition.

On 10/04/89, the RWCU system was returned to service by approximately 0400 CDT. On 10/05/89, at approximately 1526 CDT, LC01-89-468 was >

terminated following completion of the change-out of the sample line filter 1G31-D010A and restoration of flow to conductivity monitor +

1 G31 -N009. With the RWCU input to the reactor coolant conductivity monitor operable the four hour conductivity surveillance was -

-discontinued with the last sample having been taken at 1420 CDT on

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'l CAUSE'0F THE EVENT -

i The root cause of the event was cognitive personnel error. Licensed i personnel failed toLrecognize that closing valve 1G31-F020 resulted in H 1an inoperable: conductivity monitor. Consequently, compensatory actions "

were not taken to ensure that the surveillance requirements for Unit 1

_ Technical Specification section 4.6.F.2 were met.

The cause of the malfunctioning of ' conductivity monitor 1P33-N012 was that an associated pressure control valve was stuck in a throttled position resulting in inadequate flow to the monitor. -The valve was -

cycled during _ investigation of the event resulting in proper operation. >

x- REPORTABILITY ANALYSIS AND SAFETY ASSESSMENT This report:is required per 10 CFR 50.73(a)(2)(1)(B) because a condition

-existed which was prohibited by the Technical Specifications.

Specifically, reactor coolant conductivity was not monitored continuously'nor were four-hour _ measurements obtained as required by Unit 1 Technical-Specifications section 4.6.F.2 for a period of

' approximately.20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br />.

i - Reactor coolant chemistry limits are established to_ prevent damage to the stainless steel and zircaloy materials in the primary pressure

. boundary. - Reactor coolant conductivity provides an indication of l- abnormal-conditions and of the presence of unusual materials in the

reactor coolant. When the reactor coolant is greater than 212'F, the

~ Technical Specifications require that reactor coolant conductivity be maintained below 2 micro-mhos/cm. In the event, reactor coolant conductivity was approximately 0.09 micro-mhos/cm at approximately 0305 CDT, on.10/03/89. At approximately 2315 CDT on 10/03/89, the initial four-hour sample required by LC01-89-468 showed a conductivity of 0.145 -

micro-mhos/cm. The nature of reactor coolant conductivity is such that any significant increases resulting in exceeding the Technical Specifications limit would not have been abated in a 20 hour2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> period.

Based on this information, it is concluded that reactor water conductivity did'not exceed the Technical Specifications limit during

, the event.-

If the missed surveillance had not been identified as a result of the RWCU isolation, any increase in reactor coolant conductivity would have been identified during in-line conductivity analysis required by procedure 62CH-SAM-030-0S, " Primary Coolant Sampling." This analysis is performed daily and is performed independently of Technical  ;

Specifications requirements. Also, abnormal conditions affecting reactor coolant would*be identified during daily pH and chloride analysis of the reactor coolant required by 62CH-SAM-030-0S. ]

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Based on' the above information. it is concluded that this event hid no'~

adverse Limpact on nuclear plant _ safety. This analysis applies to all

' operatin'g conditions.

CORRECTIVE ' ACTIONS:

An'in-line= conductivity measurement was _obtained every four hours 'as

' required.by. the Technical: Specifications frem 2315 CDT.on 10/03/89, when the trackin'g LCG was initiated. -to 1526 CDT .on 10/05/89, when the RWCU input to the reactor coolant conductivity monitor had been restored to operable status. Personnel' involved-in the event will be counseled-

. ' regarding the consequences of this event and of the need for constant -,

, attention: to detail. ,

. ADDITIONAL INFORMATION No systems other than. the conductivity monitoring system were affected by this: event.

• Similar events in which personnel error resulted in a missed Technical

Specifications- surveillance were reported in the following LERs:

50-366/1987-016, dated 01/18/88

. 50-366/1988-005, ~ dated 03/31/88 *

' 50-366/1988-009, dated 04/18/88' 50-366/1988-019, dated 07/05/88.

50-366/1989-001, dated 02/13/89

'50-366/1939-002,~ dated 02/28/89 50-321/1989-004, dated 03/29/89 L Corrective actions for these events included disciplining / counseling responsible individuals and revising plant procedures and forms. These j ~

corrective action's would not have >revented'the event addressed in this Jreport!in that the root cause'of tie event is attributed to personnel

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L error and the~ personnel disciplined / counseled as a result of previous events were-not involved in this event.-

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