05000254/LER-1981-016-03, /03L-0:on 810902,required Surveillance Testing Not Performed Prior to Making Sgtts Train Inoperable.Caused by Personnel Error.Individuals Instructed on Need to Adhere to Procedures

/03L-0:on 810902,required Surveillance Testing Not Performed Prior to Making Sgtts Train Inoperable.Caused by Personnel Error.Individuals Instructed on Need to Adhere to Procedures

ML20011A527
Person / Time
Site:	Quad Cities
Issue date:	10/02/1981
From:	Dunesia Clark COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20011A518	List: 05000254/LER-1981-016, Forwards LER 81-016/03L-0 05000254/LER-1981-016-03, /03L-0:on 810902,required Surveillance Testing Not Performed Prior to Making Sgtts Train Inoperable.Caused by Personnel Error.Individuals Instructed on Need to Adhere to Procedures
References
LER-81-016-03L-04, LER-81-16-3L-4, NUDOCS 8110130516
Download: ML20011A527 (2)

LER-1981-016, /03L-0:on 810902,required Surveillance Testing Not Performed Prior to Making Sgtts Train Inoperable.Caused by Personnel Error.Individuals Instructed on Need to Adhere to Procedures

Event date:
Report date:
2541981016R03 - NRC Website

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U. S. NUCLEAR REGULAV@RY CoMOSSES (7 T7)

LICENSEE EVENT REPORT CONTROL BLOCK: l l

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3 EVENT DESCRIPTION AND PROBABLE CONSEQUENCES h 10I: !!

On September 2, 1981, it was discovered that surveillance testing required by I

t Technical Specification 4.7.B.I.a, had not been performed prior to making each SBGTS l 10#21 1 10 s a l I train inoperable.

The consequences of this event were minimal because each SBGTS l

train was subsequently demonstrated to be operable, and the actual time each train l

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o,3 l l was inoperable was less than I hour.

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CAUSE

CAUSE COMP.

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44 47 CAUSE DESCRIPTION AND CORRECTi\\ ACTIONS li3O[}

The cause of this event was persanc.el error.

The individuals involved did not l

follow approved procedures for the tes* ing involved.

These individuals were l

li si j l instructed on the need to adhere to procedures.

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LER NUMBER:

LER/R0 81-16/03L-0 il.

ICENSEE NAME: Commonwealth Edison Company quad-Cities Nuclear Power Station 111.

FACILITY NAME:

Unit One IV.

DOCKET NUMBER: 050-254 V.

EVENT DESCRIPTION

On September 2, 1981, at 3:30 p.m., the Shi f t Digineer was informed that the Standby Gas Treatment System (SBGTS) associated with Unit One ("B" Train) had been worbed on by Maintenance.

Subsequent investigation revealed that the surveillance testing required in Technical Speci fication 4.7.B.I.a had not L,rr performed prior to this maintenance.

It was also determined that the "A" SBGTS train had been made inoperable on August 25, 1981, to remove a charcoal test canister, and the required testing of the "B" SBGTS train was not performed.

The "A" SBGTS train had not been taken out of service prior to the canister removal. When the charcoal filter tray was renoved, thus disrupting the filter, it rendered that SBGTS train inoperable.

On August 26, the "A" SBGTS train was turned on to perform the freon leak test or the charcoal aasorber bank.

The system was run for approximately li hours.

On Ausast 28, "A" SBGTS train was operated for the equired 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br />, thus making "A" train operable.

On August 27, a charcoal test canister was removed from "B" SBGTS train wh i l e the "A" t ra i n was s t i l l inoperable.

Due to problems with the freon test equipnent, the freon leak test was not performed until September 2, 1981.

During this time, the "A" train was only operated for 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> on August 23, and 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> on August 31.

VI.

PROBABLE CONSEQUENCES OF THE OCCURRENCE:

The safety implications of this occurrence were minimal.

The rack con-taining the test canisters was removed for less than an hour.

Although the freon leak tests were not performed immediately, the results were found te be satisfactory when they were tested.

The operability tests we re also successful. Although the Technical Specification surveillance rer,airements were not rat, each train was made inoperable for less than I hour, at se:parate tin,es.

Therefore, the probability of an uncontrolled gaseous release from the secondary containment was rainimal.

Vll.

CAUSE

The cause of this occurrence is personnel error. The Maintenance and Technical Staff personnel involved did not follow the procedure, which stated that an operability test on the other train should be performed.

4 VI.

CAUSE (Continued)

Operating personnel were contacted prior to removing the test canisters as required in the Total Job Management Program.

This also failed to initiate an outage report on the train being tested.

Vill.

CORRECTIVE ACTION

The immediate corrective action was to perform an operability test on the "B" SBGTS train.

The personnel involved were reminded cf their respon-sibility to follow procedures and be aware of a Technical Specification requi rement when performing a test.

This corrective action was deemed adequate to prevent re-occurrence.

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