ML20011D420

LER 89-030-00:on 891126,containment Ventilation Isolation Initiated When Remote/Bypass Switch Moved to Remote Position.Caused by Personnel Error & Inadequate Procedure.Technician counseled.W/891219 Ltr

ML20011D420
Person / Time
Site:	Vogtle
Issue date:	12/19/1989
From:	Hairston W, Odom R GEORGIA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
ELV-01147, ELV-1147, LER-89-030, LER-89-30, NUDOCS 8912270162
Download: ML20011D420 (5)

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l l Georg.a Powt.r Comparty C 333 Pedmont Aenue Atla'ita, Gt orgir. 303C3 Tole phs tie 4D4 !J6 3195 Ma*ng Address.

' ' 40 Inerness Center Parkwag Post Ofice Box 1295 Dirmingham Alabama 3!201 Telephone 205 860 5501 December 19, 1989 the warrenee n wem W. G. Hairston. Ill Sentof VICO PrC8iderit Nuclear Operatioris ELV-Oll47

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U.' S. Nuclear Regulatory Commission l ATTN: Document Control Desk Washington, D. C. 20555 Centiemen:

V0GTLE ELECTRIC GENERATING PLANT LICENSEE EVENT REPORT PERSONNEL ERROR LEADS'TO CONTAINMENT VENTILATION ISOLATIQB

'In accordance with 10 CFR 50.73, Georgia Power Company hereby submits the enclosed report relating.to an event which occurred on November 26, 1989.

Sincerely, u/.) /N Y W. G. Hairston, 111 WGH,III/NJS/gm

Enclosure:

LER 50-425/1989-030 xc: Georaia Power Company Mr. C. K. McCoy Mr. G. Bockhold, Jr.

t Mr. P. D. Rushton Mr. R. M. Odom i? NORMS Lt V. S. Nuclear Reaulatory Commission Mr. S. D. Ebneter, Regional Administrator Mr. J. B. Hopkins, Licensing Project Manager, NRR l' .Mr. J. F. Rogge. Senior Resident Inspector, Vogtle o

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i 1 I I I I I I I I I I I I I I I l l I I I I I I I i 1 SUPPLEMENT AL REPont E KPicTID to MON 16e DAY vtAM tis fit vee. eenspwee ik9tCT(O $UOMIS$10N On til NO l l l ADST R ACT (Dedt so I400 sosces e e . soprowmeie't t'f ar** s'ap e apace repowretrea seness tiel On 11-26-89, an Instrument & Controls (I&C) technician was performing the 18-month Analog Channel Operational Test (ACOT) on Containment low range area radiation monitor 2RE-0003 The monitor's Remote / Bypass switch was in the

" Bypass" position as the technician introduced a test signal to simulate a high radiation reading. The monitor's processing unit took approximately four minutes to process the signal. However, the technician did not understand the delay and proceeded to check the gain and background signal to ensure they were correct. At 1510 CST, he moved the Remote / Bypass switch to the " Remote" i position which allowed the test signal to initiate a Containment Ventilation l

l Isolation (CVI). ,

l The root cause of this event was cognitive personnel error on the part of the technician. The procedure which was being employed to conduct the test did not address movement of the Remote / Bypass switch at the time when the technician moved it to the Remote position. The technician has been counseled regarding the importance of compliance with procedures and seeking guidance when expected test results are not achieved.

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, i A. REQUIREMENT FOR REPORT

! This report is required per 10 CFR 50.73 (a)(2)(iv) because an unplanned  ;

Engineered Safety Feature (ESF) actuation occurred.

[ B. UNIT STATUS AT TIME OF EVENT At the time of the event on 11-26-89, Unit 2 was operating in Mode 1 (Power ,

Operution) at 100% rated thermal power (RTP). Other than that described herein, there was no inoperable equipment which contributed to the .

occurrence of this event. ,

C. DESCRIPTION OF EVENT On 11-26-89, an Instrument & Controls (I&C) technician was performing the 18-month Analog Channel Operational Test (ACOT) on Containment low range area radiation monitor 2RE-0003. The monitor's Remote / Bypass switch was in the " Bypass" position as the technician introduced a test signal to simulate 5 a high radiation reading. The monitor's processing unit took approximately 4 minutes to process the signal. However, the technician did not understand '

the delay and proceeded to check the gain and background signal to ensure they were correct. At 1510 CST, he moved the Remote / Bypass switch to the

" Remote" position which allowed the test signal to initiate a Containment Ventilation Isolation (CVI). The appropriate valves and dampers actuated and control room operators verified that no abnormal radiation condition -

existed. The CVI signal was reset at 1547 CST.

D. CAUSE OF EVENT The root cause of this event was personnel error on the part of the Georgia Power Company technician. Procedure 24623-2, " Containment low Range Area Radiation Monitor Analog Channel Operational Test", which was being employed i to conduct the test, did not address movement of the Remote / Bypass switch at l the time when the technician moved it out of bypass. l The following are contributing causes of this event:

1. The test procedure indicates that testing should cease if expected .

results are not being obtained. When the technician did not understand the lengthy processing time, he failed to stop and notify his foreman as indicated by the procedure.

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2. The test procedure did not indicate that a lengthy processing time may be required (depending on the test signal frequency used). This lack of information misled the technician into believing that the signal was not being processed.

3. Although the technician performing the ACOT testing was trained and qualified to do surveillance testing, this was only the second time he had performed testing on 2RE-0003. This lack of specific experience contributed to his personnel error.

4. Operational needs for blocking the ESF actuation signal during maintenance and testing were not addressed in the original design.

The above cognitive personnel errors were not the result of any unusual characteristics of the work location.

E. ANAL.YSIS OF EVENTS During this event, the CVI signal actuated the proper valves and dampers and I control room operators responded correctly in verifying that no abnormal radiation condition existed. Therefore, plant safety would have been maintained if an abnormal radiation condition had, in fact, existed. Based on these considerations, there was no adverse effect on plant safety or public health and safety as a result of this event. t l F. CORRECTIVE ACTIONS

1. 'The technician involved has been counseled regarding the importance of compliance with procedure and seekin0 guidance when expected test results are not achieved. Personnel responsible for performing i maintenance or surveillance activities on Process Effluent Radiation i Monitoring System (PERMS) monitors have been reminded of the necessity i to stop testing and seek guidance whenever expected test results are not I being achieved. '

2. Procedures 24623-1 and 2 have been changed to advise personnel of the  ;

potential for a lengthy test signal processing time. j

3. An additional instructional unit will be developed for this specific 4 ACOT testing by 2-1-90. Additional PERMS hands-on training will be instituted upon receipt and installation of the PERMS training simulator. ,

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4. A blocking capability is being designed with installation currently planned for 1990.

G. ADDITIONAL INFORMATION

1. Failed Components None

2. Previous Similar Events LER 50-424/1989-001, dated 02-01-89.

Corrective action addressed means to prevent inadvertent actuation of IRE-0003's reset button. However, it did not address movement of the Remote / Bypass switch.

LER 50-424/1988'-027, dated 10-26-88.

Corrective action addressed lack of a switch to block the CVI actuation-signal. Installation of these switches is scheduled to occur during 1990.

L 3. Energy Industry Identification System Code ~

L Containment Isolation Coltrol System - JM L Radiation Monitoring System - IL l

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