ML20011D881

LER 89-020-00:on 891211,power Removed from Radiation Monitor Before Lifting Leads to ESF Actuation Circuits.Caused by Cognitive Personnel Error & Failure to Follow Procedure. Technician Disciplined.Esf Provisions planned.W/891221 Ltr

ML20011D881
Person / Time
Site:	Vogtle
Issue date:	12/21/1989
From:	Hairston W, Odom R GEORGIA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
ELV-01183, LER-89-020-01, NUDOCS 9001020221
Download: ML20011D881 (4)

Text

George Powin Company 333 heanort Annue

. Att2nta, Georg.a 30308 Teiephore 4D4 52$ 3195 j p . Mabng Accrets

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December 21, 1989 W. G Hairston. Ill senor vec Prei.ent  ;

Nuoear owatons ELV-Oll83 0176 Docket No. 50-424 f U. S. Nuclear Regulatory Commission f ATTN: Document Control Desk l Washington, D. C. 20555  :

Gentlemen:

V0GTLE ELECTRIC GENERATING PLANT LICENSEE EVENT REPORT PERSONNEL ERROR LEADS TO CONTAINMENT VENTILATION ISOLATION t

in accordance with 10 CFR 50.73, Georgia Power Company hereby submits the ,

enclosed report relating to an event which occurred on December 11, 1989.  :

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Sincerely,

. . h W. G. Hairston, Ill WGH,Ill/NJS/gm

Enclosure:

LER 50-424/1989-020 ,

xt: Georaia Power Company l

Mr. C. K. McCoy Mr. G. Bockhold, Jr.

Mr. P. D. Rushton l

Mr. R. M. Odom '

l NORMS l M. S. Nuclear Reaulatory Commission l l Mr. S. D. Ebneter, Regional Administrator -

t Mr. J. B. Hopkins, Licensing Project Manager, NRR Mr. J. F. Rogge, Senior Resident Inspector, Vogtle 1

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On 12-11-89, an Instrument and Controls (I&C) technician was preparing to check the fuses in Containment low range area radiation monitor 1RE-0003. At 1034 <

CST, he removed power from the monitor prior to lifting the leads to the Engineered Safety Features (ESF) actuation circuits. The loss of power caused the monitor to revert to its failed, or safe, condition which sent a high alarm signal to ESF actuation circuits, initiating a Containment Ventilation Isolation.

The root cause of this event was cognitive personnel error on the part of the technician in not adequately following procedure. The technician will be disciplined and provisions for blocking the ESF actuation signal during maintenance and testing are currently planned for installation in 1990.

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A. REQUIREMENT FOR REPORT

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This report is required per 10 CFR 50.73 (a)(2)(iv) because an unplanned l Engineered Safety Feature (ESF) actuation occut red, j i

B. UNIT STATUS AT TIME OF EVENT At the time of the event, Unit I was operating in Mode 1 at 100% of rated thermal power (RTP). Other than that described herein, there was no  !

inoperable equipment which contributed to the occurrence of this event. i l

C. DESCRIPTION OF EVENT l

On 12-11-89, an Instrument and Controls (l&C) technician was preparing to check the fuses in Containment low range area radiation monitor 1RE-0003.

At 1034 CST, he removed power from the monitor prior to lifting the leads to i the Engineered Safety Features (ESF) actuation circuits. The loss of power ,

caused the monitor to revert to its failed, or safe, condition and this safe '

condition sent a high alarm signal to ESF actuation circuits. A Containmeat l Ventilation Isolation (CVI) occurred and the appropriate valves and damperJ i actuated to their proper positions. Control room personnel responded to l verify that no abnormal radiation condition existed and the CVI signal was i reset at 1153 CST.

D. CAUSE OF EVENT The root cause of this event was personnel error on the part of the Georgia Power Company technician. Procedure 24623-1, " Containment Low Range Area Radiation Monitor Analog Channel Operational Test," which is used for '

general maintenance activities as well as Technical Specification surveillances, was attached to and referenced on the work order for checking the fuses. The procedure requires the ESF actuation circuit leads to be lifted prior to removing power from the monitor. However, the technician ,

neglected to consult the procedure. This cognitive personnel error was not the result of any unusual characteristics of the work location.  !

The following are contributing causes for this event:

1. Department policy did not require use of procedure check-off blocks when performing non-routine activities of this type. The procedure is used for performing Technical Specification surveillances as well as for general maintenance activities but does not detail all possible activities which may need to be performed. However, the procedure provides a means for self-checking which should be employed when possible, ge.o.. .

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2. No caution label exists on the monitor to advise personnel of the potential for initiating an ESF actuation by removing power.

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

E. ANALYSIS OF EVENT During this event, the CVI signal actuated the proper valves and dampers and 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 these events.

F. CORRECTIVE ACTIONS The Positive Discipline Program will be enacted for the technician involved in this event.

The following are contributing factor corrective actions:

1. An I & C policy statement will be issued stressing the need for using self-checking blocks when appropriate. Also, all appropriate personnel will be coached on the importance of using procedures.

2. Permanent caution labels will be placed on the exterior of the radiation monitor data processing modules"(DPM's) advising of the potential for initiating ESF actuations.

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

G. ADDITIONAL INFORMATION

1. Failed Components None

2. Previous Similar Events:

LER 50-424/1988-027, 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,

3. Energy Industry Identification System Code Containment Isolation Control System - JM Radiation Monitoring System - IL 1

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