ML20012E993

LER 90-008-00:on 900227,determined That Surveillance Procedure M-280-0 Did Not Include Steps to Fully Test Control Room Recorder for Hydrogen Analyzers.Caused by Personnel Error.Procedure Revised on 900308.W/900329 Ltr

ML20012E993
Person / Time
Site:	Calvert Cliffs
Issue date:	03/29/1990
From:	Denton R, Muth D BALTIMORE GAS & ELECTRIC CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-008, LER-90-8, NUDOCS 9004090268
Download: ML20012E993 (7)

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A BALTIMORE I

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• P.O. BOX 1475 e BALTIMORE. MARYLAND 21203 1475  ;

CALVERT Cliff 8 NUCLEAR POWER PLANT DEPARINENT  !

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. March 29, 1990 l I

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'U. S. Nuc1 car Regulatory Commission Docket No. 50 317 . {

Document Control Desk License No. DPR 53 ,

Warbington, D. C. 20555

Dear Sirs:

The attached LER 90 08, Revision 0, is being sent to you as required under 10 i CFR 50.73 guidelines.

Should you have any questions regarding this report, we would be pleased to i discuss them with you.

_ _Vg truly yours ,

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t-DWM/Ir I? 1 cc: William T. Russell Director, Office of Management Information and Program Control Messrs: G. C. Creel C. H. Cruso l- J . R. Lemons L. B. Russell N , R. P. Heibel -

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20 406 ellinel to t3ian2nml to Pawn 2nal LICEN8EI CONT ACT 90R THl4 LtR n21 N '.M t YlktPHONE NVMuth eht A CWL D. W. Muthe Compliance Engineer 3l0 t 1 216 l 01 - 131519 l2 COMPLif t ONt LINT FOR B ACH COMPONENT S AILURf DISCRiDIO QN THil REPORT ital C *-Ulf tvlf t =* COMPONtN1 "( [ "(([phY CAvst 8vsflu COMPONtNT "$'c j ntroRIA E i l l i i 1 1 1 l l 1 I I 4 I l l l l ! I l I I i l I l BuPPLEMENT AL REPORT E APICitD ital MON 1H DAY vtAR Ev8 Met $ ION vtb (19 res. eeme.or. ikPICilO 5V04,1SSION OATil NO l l l AuTeci it . im u < . . . . ..r... a, ... . , .. ..o nei On February 27, 1990, with Unit 1 in Mode 5 and Unit 2 defueled, the procedural controls governing the calibration of the hydrogen analyzers were determined to have created a condition prohibited by the plant's Technical Specifications and therefore reportable under 10 CFR 50.73(a)(2)(1)(B). The System Engineer found that Surveillance Test Procedure M 280 0 " Hydrogen Analyzer Calibration Check", did not include steps to fully test the control room recorder for the hydrogen analyzers or the complete circuitry leading from the hydrogen analyzers to the recorder.

The cause of this condition was personnel error with inadequate procedural controls as a contributing cause.

STP M 381-0 was wrJ tten on March 8, 1990 to include the complete loop calibration check. STP M 280 0 was revised on March 8, 1990 to make it compatible with STP H 381 0. Performance of both STPs was completed by March 20, 1990.

The revised C01-101, "Calvert Cliffs Impicmenting Procedure Development and Control," requires that the Technical Specifications being met by a procedure must be clearly identified near the be6 nning 1 of the procedure.

We have instituted a Performance Improvement Plan item requiring the review of STPs for technical adequacy relative to the Technical Specifications.

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0jo 0l2 0F 0l6 I. DISCUSS 11}H G5 b>br w ty 27, 1990, with Unit 1 in Mode 5 and Unit 2 defueled, the procedural G ottnis t,overning the calibration of the hydrogen analyzers (EIIS BB.AE) vece determined to hm created a condition prohibited by the plant's Technical '

Specifications and tae t el fore reportable under 10 CPR 50.73(a)(2)(1)(B). The System Engineer found that S wvoillance Test Procedure (STP) M 280 0 "llydrogen Analyzer Calibration Check", did not include steps to fully test the control room recorder (EIIS BB AR) for the hydrogen analyzers or the complete circuitry leading from the hydrogen analyzers to the recorder.

Technical Specification 4.6.5.2 requires that a channel calibration be performed every 92 days to verify that the hydrogen analyzer is operable. A channel cailibration should encompass the whole circuit including recorders. Local indication (EIIS BB AI) in the area of the analyzers was calibrated but not the control room recorder.

Since both units are shut down, the action requirements of Technical Specification 3.6.5.1, which require that the plant be in llot Shutdown within 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> of discovery, were not applicable.

The channel calibration of the complete loop was satisf!.ed by STP M 380 0, "flydrogen Analyzer Calibration Check". In mid 1987, the hydrogen analyzer calibration was moved to STP M 280 0 and the calibration of individual components in the loop, including the control room recorder, was moved to Preventative Maintenance (PM) Card Number 2 38 I RQ2 202. The PM was scheduled to be performed on a refueling interval basis. As stated above, the calibration of the complete loop should be performed every 92 days. This condition existed approximately two and a half years. There are no other structures, systems or components that contributed to this event.

II. GAUSE OF CONDITION The cause of this condition was personnel error with inadequate procedural controls as a contributing cause. The loop check should not have been removed from the calibration procedure. Although the components in the loop are individually tested in the PM, the entire loop was not calibrated at one time and the frequency of the PM did not match the Technical Specification surveillance requirement regarding frequency of performance. The personnel who revised the procedure did not have available to them adequate design basis documentation for the hydrogen analyzer. This contributed to the lack of knowledge that caused the personnel error.

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The procedural controls in place at the time were inadequate to ensure that the full intent of the Technical Specification was met when the STP was revised.

The historical root cause of inadequate procedures has been previously identified in the Performance Improvement Plan, which specifically cites inadequate control for capturing the bases for procedure changes as they are made and over reliance on worker knowledge and experience.

III. ANALYSIS There are two hydrogen analyzer systems, each of which receives input from both units. The hydrogen analyzers were installed in response to NUREG 0737 item 11.F.1.(6), " Accident Monitor, Containment Hydrogen." The purpose of the analyzers is to provide Control Room operators with indication of the level of hydrogen in containment after a Loss of Coolant Incident (LOC 1). This information is used by the operator to determine whether or not to turn on the hydrogen recombiners (EIIS BB RCB), which remove hydrogen from the containment atmosphere. The hydrogen analyzers also serve to inform the operator if the i recombiners are not functioning.

Figure 1 is a block diagram of the hydrogen analyzer system. Device 1 is the hydrogen analyzing cell (AE 6519) and its associated electronics (AY 6519). ,

Device 2 is the isolator (EIIS BB AB) (E/I-6519A) feeding the output signal to Devico 3, the control room recorder (AR 6519). Devices 4 and 5 are the l local indicators in the 45 foot and 10 foot levels of the Auxiliary Building, respectively.

STP M 280 0 required that Devices 4 and 5, the local indicators, be in

, calibration with one another. The STP did not requiro measurement of the l output voltage leading from the analyzing cell to the control room recorder. It l was possible for this voltage to drift, causing inaccurate readings in the control room. This condition would not have been detected using STP 280 0 or the PM.

I The input from the hydrogen analyzers is only relied on during certain LOCI scenarios. The control room recorder indicates the level of hydrogen on a scale from 0 to 10 percent. The administrative limit for turning on the recombiners is 1 percent hydrogen. The level assumed in the Final Safety Analysis Report is 3 percent hydrogen.

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IV. CORRECTIVE ACTIONS

1. STP M 3810 was written on March 8, 1990 to include the complete loop calibration check. STP M 280 0 was revised on March 8, 1990 to make it compatibic with STP M 381 0. Performance of both STPs was completed by March 20, 1990, as discussed above.

2. Calvert Cliffs Instruction 104, " Surveillance Test Program", now assigns Functional Surveillance Test Coordinators (FSTCs) responsibility for overseeing and maintaining their assigned STPs. Each FSTC is required i to ensure that all Technical Specifications associated with a given STP l are fully implemented in the STP. All new or revised STPs receive a j review using strict guidelines designed to ensure compliance with technical specifications. New or revised procedures will also receive a  ;

review by the System / Component Engineer or appropriate technical expert as well as the department responsible for performing the procedure.

3. The revised CCI 101, "Calvert Cliffs Implementing Procedure Development and Control," requires that the Technical Specifications being met by a procedure must be clearly identified near the beginning of the procedure.

4. We have instituted a Performance Improvement Plan item requiring the review of STPs for technical adequacy relative to the Technical Specifications. The goal of this review is to assure that STPs are consistent with Technical Specification requirements. This review will also identify the design basis of the equipment associated with each STP.

The circumstances relative to this event will be factored into the priority and the schedule of this review. I p,RC F.rm3064(649)

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V. MDITIONAL INK)RMATION Similar problems with procedural implementation of Technical Specifications were documented in LERs 318/88 006, 317/88 001, 317/89 010, 317/89 013, 317/89 017, 318/89 022, 317/89 024, 317/90 001 and 317/90 007.

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