ML19332E752

LER 89-016-00:on 890917,unplanned Release of Radioactive Resin to Onsite Settling Basin Occurred.Caused by Personnel Error.Standing Order 89-051 Generated on 890920 to Direct Use of Working Copy of procedures.W/891204 Ltr

ML19332E752
Person / Time
Site:	Davis Besse
Issue date:	12/04/1989
From:	Storz L, Stotz J TOLEDO EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-016, LER-89-16, NP33-89-018, NP33-89-18, NUDOCS 8912120080
Download: ML19332E752 (5)

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EDISON PMZA 300 MADISON AVENUE TOLEDO. OHIO 43652 0001 December 4,1989 Log No.: BB89-01254 NP33-89-018 Docket No. 50-346 License No. NPF-3 United States Nuclear Regulatory Commission Document Control Desk

-Vashington, D. C. 20555 Gentlement LER 89-016 Davis-Besse Nuclear Power Station, Unit No. 1 Date of Occurrence - September 17, 1989 Enclosed Licensee Event Report 89-016 which is being provided in accordance with 10CFR50.73(a)(2)(1) to provide written notification of the subject occurrence.

Yours truly, s,/' ~ ,

h1M e Louis F. Storz Plant Manager Davis-Besse Nuclear Power Station LFS/p1f Enclosure cc: Mr. A. Bert Davis Regional Administrator USNRC Region III Mr. Paul Byron DB-1 NRC Sr. Resident Inspector 8912120080 891204 ADOCK 0500034,6 f6 7;

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NRC Pere 300 , U.S. NUCLEAR CESULATOUY COMM198 SON APPROVID OMS NO. 31EO.01M exnats. or3ima

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F ACILITY NAME (1) DOCKET NUMSER (2) PA(sE Gs Davis-Besse Unit No. 1 o l5 l 0 l0 l 0 l 3l4 l 6 1 jopl0 l 4 TITLE 44)

Unplanned Release to Settling Basin During Condensate Polisher Backwash EVENT DATE (El LER NUMSER (S) REPORT DATE (7) OTNER F ACILITIES INVOLVED (8) 8 3,0 DOCKET NUMBERt3) 9 % ',

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NAME TELEPHONE NUMBER AREA CODE Jan C. Stotz, Engineer - Maintenance Planning 4l 119 312l1 l-1715 l4l4 COMPLETE ONE LINE FOR EACM COMPONENT P AILURE DESCRISED IN THIS REPORT (13)

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On September 17, 1989, during a planned backwash of the No. 1 Polisher to the No. 2 Condensate Polisher Demineralizer Holdup Tank, an unintended release of radioactive resin to an onsite settling basin occurred. Conservative estimates concluded that 23 cubic feet of resin and 12,000 gallons of water were released to the basin.

This results in a dose to the public from the backvash liquid of 1.68 E-6 mrem. The <

cause of the release was personnel error by the equipment operator who left three valves out of position. The condenser pit sumps, which use a section of the Backwash Receiver Tank discharge lines when.the sumps are directed to the settling basin, vere not isolated before the backwash. Although a controlled copy of DB-CH-06017 was available and referenced for this evaluation, the. steps were not signed off since this had been considered a routine operation. Personnel involved were counseled on the significance of attention to detail.

The Condensate Polisher Demineralizer Backwash Operating Procedure, DB-CH-06017, was changed (TA89-5959) on October 10, 1989, to provide specific direction for required valve lineup to support the resin transfer.

Standing Order 89-051 was generated September 20, 1989, to direct the use of a working copy of procedures and signoff of steps. This standing order is applicable to Operations and Chemistry personnel who conduct this operation. Additionally, Toledo Edison is currently reviewing all procedures dealing with the handling of radioactive effluents. Any deficiencies that could lead to an unplanned release vill be corrected. The review vill by completed by December 31, 1989.

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01 0 d2 OF 014 TEXT M aume apsse e seguseet use eastusenWIC poun m W 114 Description of Occurrence:

On September 17, 1989,-during a planned backvash of the No. 1 Condensate Polisher to the No. 2 Condensate Polisher Domineralizer Holdup Tank (CPDHUT),

an unintended release of radioactive resin to an onsite settling basin occurred. Using conservative estimates, there vere 23 cubic feet of condensate polisher resin released with a backwash water activity of 9.52E-4 micro C1/ml. The normal backwash operation would direct the resin to the Backwash Receiver Tank (BVRT) or'to the CPDHUT where the contents could be sampled and then released to the settling pond or if desired, controlled and disposed of as lov level radioactive vaste.

The unintended release was below the limits of 10CFR50.73(a)(2)(viii)(B) even with the conservative estimate of activity. Technical Specification 3.11.1.1 limits the concentration of radioactive material released in liquid effluents to unrestricted areas. The related Surveillance Requirement 4.11.1.1.1 includes a pre-release sampling and analysis. However, since the release was unplanned, there was no pre-release sampling performed. This is being submitted as a missed surveillance requirement which is reportable under 10CFR50.73(a)(2)(1)(B) as a condition prohibited by Technical Specifications.

The report date is beyond 30 days of the event date. Toledo Edison personnel had originally reviewed this event for reportability and determined that an LER was not required. The release was well belov the limits of 10CFR50.73(a)

(2)(viii)(B) (2 times 10CFR20 limits). It was not reportable under paragraphs '

(v) and (vi) as a procedural violation. It was also thought not to be reportable under paragraph (1)(B) as a condition prohibited by Technical Specifications since the surveillance requirement in question vas-a ,

pre-release sampling. The planned activity was not a release but rather a transfer of resin from a polisher to a holdup tank with no intention of releasing to the environment. Therefore, the incident was determined not to be reportable as an hER. This reasoning had been reinforced at an industry seminar, October 4, 1909, at which AE0D personnel participated.

However, after discussions with the NRC Region III, AE0D, and NRR on October 31, 1989, Toledo Edison agreed to report this event as a condition prohibited by Technical Specifications. The intent of the surveillance was to provide sampling prior to releasing potentially radioactive material to unrestricted areas. Therefore, this event (personnel / procedural error resulting in a release) should be reported because no pre-release sample was performed.

Apparent Cause of Occurrence:

The cause of the release to the settling basin was personnel error by the equipment operator inadequately aligning valves on a routine evolution due to not using the applicable procedures. This resulted in three valves being l

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0l0 Ol 3 0F 0l4 text nm seen. w, e .mme wme a asumm in incorrect positions when the backvash was started. The inlet valve to the CPDHUT, CD237, was closed instead of open. The BVRT discharge to holdup i tanks, CD124, and the BVRT discharge to the settling basin, CD125, vere both j open instead of closed. CD124 and CD125 had been in the open position because  ;

the east and vest condenser pit sumps vere being directed to the settling  :

basin rather than the storm sever due to our present condition of a minor l steam generator tube leak. When the pumps are lined up to the settling  ;

basins, they use a section of the BVRT discharge lines. With CD237 closed and CD124 and CD125 open, the backwash of a Condensate Polisher gets directed through CD124 and CD125 and on into the settling basin. The procedure prerequisites required the Valve Verification List for the Condensate Polisher Demineralizer Backwash Operation to be complete. This list requires CD124 and.

CD125 to be closed. The sumps should have been isolated for the duration of the backwash operation, j Although a controlled copy of DB-CH-06017 was being referenced for this 1 backwash operation, the steps were not signed off as they were completed. For  !

routine operations, this is allowed. However, in this case, it may have  !

contributed to the errors, i

Analysis of Occurrence:

The total volume and activity released from the backwash of the No. 1  :

Condensate Polisher into the onsite settling basin was conservatively l estimated as be3ng 9.52E-4 micro C1/ml for 12,000 gallons. This assumed that  ;

all of the resin and all of the water from the backwash was released to the settling basin. Only the backwash liquid was discharged offsite via the  !

normal diluted effluent flovpath. This resulted in a calculated dose to the  ;

public from liquid radvaste of 1.68E-6 mrem. Therefore, the amount of  !

i radioactivity released is insignificant relative to limits.

Corrective Action to Prevent Recurrence:

The personnel involved were counseled on the significance of attention to detail. DB-CH-06017 was changed (TA89-5959) on October 10, 1989, to provide specific Euldance for isolating the condenser pit sumps, if they'are lined up to the settling basin, before backwashing a polisher to the CPDHUT. It also eliminated the seven page Valve Verification List and incorporated a less - .

extensive list into the body of the procedure with signoffs. }

t Standing Order 89-051 was generated and in effect September 20, 1989, and nov  ;

requires the use of vorking copies and signoff of steps for all Condensate j Polisher Backwash operations. This covers the secondary side operations that i were formerly considered routine which now have a potential for releasing l radioactive materials to the environment.

Additionally, Toledo Edison is currently reviewing all procedures dealing with the handling of radioactive effluents. Any deficiencies that could lead to an unplanned release vill be corrected. The reviev vill be completed by December 31, 1989.

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texten - w =ac % ,m4w nn Failure Data This is the second report of an unplanned release in 1989. The previous report, LER 89-012, was caused by a typographical error in a procedure which directed the operator to the wrong valve lineup list.

REPORT NO.: NP33-89-018 PCAO NO.: 89-0453 i

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