ML20043A787

LER 90-016-00:on 900421,determined That Waste Gas Decay Tank (Wgdt) 13 Discharged Instead of (Wgdt) 11 for Discharge Permit Issued.Caused by Inadequate Communications.Training Performed for Operators Re event.W/900521 Ltr

ML20043A787
Person / Time
Site:	Calvert Cliffs
Issue date:	05/21/1990
From:	Denton R, Volkoff J BALTIMORE GAS & ELECTRIC CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-016, LER-90-16, NUDOCS 9005230124
Download: ML20043A787 (6)

Text

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BALTIMORE GASAND t ELECTRIC CHARLES CENTER e P.O. BOX 1475

• BALTIMORE MARYLAND 21203 1475 i

R. E. DE NTON MANAGtft i CAtytRT Cuf f 5 ,quCtg AR POW 6R PLANT DtFARTMeest May 21, 1990 U. S. Nuclear Regulatory Commission Docket No. 50 317 Document Control Desk 1.icense No. DPR 53 Wshington, D. C. 20555

Dear Sirs:

The attached LER 90 16, Revision 0, is being sent to you as required under 10 CFR 50.73.

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

Very truly yours, i

W~

[O R. E. Denton -

JV/kn ec: Thomas T. Martin Director, Office of Management Information and Program Control Messrs: G. C. Creel C. H. Cruse J. R. Lemons L. B. Russell R. P. Heibel q

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At 0030, on April 21, 1990, during shift change, an operator determined t. h a t Waste Gas Decay Tank (WGDT) #13 was being discharged instead of WGDT Wll, for which a discharge permit had been issued. The discharge was stopped and #13 WGDT sampled to calculate the amount of radiological material released. It was detern:ined that the release was wit hin Technical Specifications. It was also determined that in the event of the limiting waste gas incident occurring, dose at the nearest exclusion area boundary would be within the 10CFR100 guideline value. At the time Unit-1 was operating (MODE 1) at 65% power, a temperature of 540 degrees F and a pressure of 2250 psia.

Inadequate communications between the Unit-1 (U-1) Control Room Operator and the U-l Auxiliary Building Operator was the root cause of the event. Inadequate specific directions of Calvert Cliffs Instruction (CCI)-309, Locked Valves, contributed to the event.

Training will be performed for operators on this event emphasizing the importance of the use of formal communications. CCI-309 will be revised to provide more stringent administrative control of locked valve operation. An evaluation will be performed to determine if site wide requirements governing formality in communications are adequate Nac . m m a

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0 l0 0 12 0F 0 l5 TEKT W mews apose a soppost oss ashesoniW NRC Perm Ws/ (IM I. DESCRIPTION OF EVENT At 0030 on April 21, 1990, during shift change, an operator determined that Waste L Gas Decay Tank (WGDT) #13 was being discharged instead of WGDT #11, for which a j discharge permit had been issued. The discharge was stopped and #13 WGDT sampled to calculate the amount of radiological material released. We determined that the release was within TSs. At the time Unit-1 (U-1) was operating (MODE 1) at  !

65% power, a temperature of 542 degrees F, and a pressure of 2250 psia.

11. BACKGROUND The WGDTs store waste gas from the plant to allow time for the radionuclides to decay. A WGDT is taken off service when the pressure in the tank reaches i approximately 140 psia. The gas is discharged after the WGDT has been sampled and the activity of the gas has been determined. At 1800 on April 20, 1990, WGDT

1. 11 was at 138 psia and UGDT #13 was at 142 psia.

At approximately 1800 on April 20, Plant Chemistry, f delivered a waste gas release permit 1990, to thethe Operations supervisor, . Shift Supervisor.

The permit was for the release of the contents of WGDT #11.. The Shift Supervisor gave the permit to the Control Room Supervisor (CRS). The CRS gave it to the U-1 Control Room Operator (CRO) and directed him to discharge # 11 WGDT. At this time, #11 and #13 WGDTs wet isolated and #12 WGDT was in service.

At 1830, the U-1 Auxiliary Building Operator (ABO) reported to the U 1 Reactor Operator that #13 WGDT pressure was at 142 psig, 2 psi above the high limit on the ABO logs. The ABO also reported that #12 WGDT was verified in service and asked that the information be passed on'to the CRO. 1 At approximately 1915, the U-1 ABO called the U 1.CR0 to verify that he - had received the report about WGDT #12 being verified in service. During this conversation, the CR0 noted that a release permit had been received for #11 WGDT ,I and that the discharge would be done as time permitted. After the event, the ABO did not remember the specific WGDT to be discharged being mentioned in _ the conversation. The ABO believed that #13 WGDT was to be discharged based on its higher pressure which was greater than the maximum specified in his log. The ,

WGDT to be discharged was not specified again in communications subsequent ' to this conversation.

At approximately 2145 the line up to discharge a WGDT was begun. The U l ABO  ;

reported to the U 1 CR0 that he was ready to begin'the line up. The CR0 directed I the ABO to perform the applicable steps in Operating Instruction (01)-17, Waste Gas System, for release, but the CR0 thought that WGDT #11 was being discharged,  ;

while the ABO thought that WGDT #13 was to be discharged.

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The step in 01 17B that opens the last valve in the line up, starting the discharge, contains 3 valves. Each valve corresponds to a different WGDT. The U1 ABO reported back to the CR that he had completed the step in 01 17B beginning the discharge, but did not specify which valve.had been opened or which ,

l WGDT was being discharged. The U 1 ABO monitored the discharge locally to ensure the discharge was proceeding as he expected, which was for WGDT #13 pressure to decrease, which it did.

A valve deviation sheet was not used prior to the operation of the locked valves operated in 01-17B. This was procedurally permissible due to a weakness in Calvert Cliffs Instruction (CCI) 309, Locked Valves, i

The WGDT pressure was not monitored in the Control Room (CR) because the U-2 Plant Computer, which provides the only signal to CR instruments that provide indications of WGDT pressures, was Out of-Service (OOS). 1 At approximately 2325, the U 2 ABO, who was assisting the U l ABO, checked to see if a valve deviation sheet had been filled out for the locked valves operated in the discharge procedure. The U-2 ABO discovered that no sheet had been filled out and completed one for two of the valves operated in the procedure. The CR0 checked the valve deviation sheet and found that one of the valves operated had not been entered on the sheet. He entered and initialed for the valve. However, he entered the valve for discharging from #11 WGDT. The U 1 ABO did not initial the valve deviation sheet.

While the next shift was taking the watch from the U 1 ABO, the oncoming ABO noted that at the shif t briefing, #11 WGDT was reported as being discharged. The oncoming ABO determined that #13 WGDT was being discharged and informed the CR.

The release was terminated at 0030 and the Plant Chemistry Unit was notified. A release permit for #13 WGDT was completed based on sample results of the contents remaining in the #13 WGDT.

III. CAUSES l The root cause of this event was inadequate ecmmunications. The -U-1 CR0 identified that #11 WGDT was to be discharged during the shift in a conversation with the U 1 ABO. However, the identity of the WGDT to be discharged was never restated in subsequent communications relating to the release. The ABO did not repeat the order back when he received direction regarding which WGDT was to be discharged. The ABO assumed that the CR0 wanted to discharge #13 WGDT, which he had previously reported as . having a pressure above the normal limit. The CR0 assumed that the ABO would discharge #11 WGDT based on the conversation that took place earlier in the shift.

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L CCI-309 governs the operation of locked valves to prevent their inadvertent L operation, llowever , the procedure is primarily designed to ensure that locked valves are returned to their normal position. The procedure does not provide effective controls for positioning locked valves out of their normal position.  ;

C01-309 is unclear as-to when and how a valve deviation sheet should be used when 1

taking locked valves out of their normal positions. As a result, a valvo l deviation sheet was not used prior to valve operation and ~ the U.1 ABO did not initial the valve deviation sheet.

Contributing to the event was the lack of the WGDT pressure monitor in. the Control Room because the-U 2 computer was not operational.

IV. ANALYSIS This event is reportable under 10 CFR 50.73(a)(2)(1)(B), an operation prohibited by the plants Technical Specifications-(TS). TSs require that.a sample be-drawn j fron a WGDT prior to its discharge. A sample was not drawn prior to discharging  ;

1. 13 WGDT.

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Based on calculations of the amount of radioactive gas released, the release was within TS limits.

A Chapter 14.22 of the updated Final Safety Analysis Report analyzes a rupture of i the waste gas decay tank to define the limit of the hazard that could result in ,

i any malfunction in the radioactive waste gas system. The maximum activity in any l WGDT is assumed to occur shortly after, n cold start up of .one_ unit near the end  !

of an operating cycle. It is also assumed that :this unit has been operating for I an extended period with one percent defective fuel and that all of the coolant is let down. The noble gases from one reactor coolant system volume are stored in  ;

one WGDT. i In the unlikely event of a rupture of the WGDT, the. dose-at the nearest exclusion zone boundary is a factor of 50 less than the 10CFR100 guideline value.

Therefore, a WGDT rupture does not represent undue hazard to the public health or .'

safety.

Under-normal circumstances, the activity of the waste gas released from the WGDTs f is.at least two or three orders of magnitude less than the activity considered in  ;

the analyzed event. In accordance with Technical Specifications, the main vent 1 radiation monitoring system was operating and readings - were recorded every 15 j minutes during this release. The main vent monitor alarm setpoints were set based on the discharge permit prepared for a WGDT #11. If the alarm setpoint '

had been reached, the release would han a been secured. Thus, if a WGDT containing a substantially higher actWi.tv had been released by mistake, the alarm setpoint would have been reached W. the release secured. These factors further mitigate the safety significance of this event.

NRC form 306A (649) i

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0 l0 0l5 0F 0 l 'i l rixi in a m.w. w Nac w menwim V. CORRECTIVE ACTIONS Shift Supervisors will review this event - with their shifts, emphasizing the iniportance of formality in communications. Specifically, according to Operations Section policy, when communicating, directions given shall be clear, precise and component specific. The directions are to be repeated back .in sufficient detail to ensure that they were understood.

An evaluation will be performed to determine if site wide requirements at Calvert Cliffs governing formality in communications are adequate.

CCI 309 will be revised to provide more stringent administrative control of locked valve operation. ,

1 OI 1~/B will be revised to require that during WGDT discharge either WGDT pressure be monitored in the Control Room or an alternate method be used to verify that the correct WGDT is being discharged.

i VI. ADDITIONAL INFORMATION A. Previous similar event.

No previous similar events involving inadvertent discharge of a WGDT have been noted at Calvert Cliffs.

B. Affected component identification.

IEEE 805 IEEE 803 Component System ID Comnonent WGDT WE TK Valve WE VTV NRC Poesn 386A (649)