ML20043B112

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LER 90-005-00:on 900420,condenser Vacuum Pump Discharge Wide Range Gas Monitor Setpoint Discovered to Be Incorrect.Caused by Inadequate Change Procedure for Data Base Manual. Administrative Procedures revised.W/900521 Ltr
ML20043B112
Person / Time
Site: Waterford Entergy icon.png
Issue date: 05/21/1990
From: Labonte W, Mcgaha J
LOUISIANA POWER & LIGHT CO.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-005, LER-90-5, W3A90-0156, W3A90-156, NUDOCS 9005240203
Download: ML20043B112 (6)
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Ref: 10CFR50.73(a)(2)(i)  !

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U.S. Nuclear Regulatory Commission ATTENTION: Document Control Desk Washington, D.C. 20555

Subject:

Waterford 3 SES Docket No. 50-382 License No. NPF-38 Reporting of Licensee Event Report Centlement Attached is Licensee Event Report Number LER-90 005-00 for Waterford Steam Electric Station Unit 3. This Licensee Event Report is submitted pursuant to 10CFR50.73(a)(2)(i).

Very truly yours, J.R. McGaha Plant Manager - Nuclear JRM/JEF/rk l (w/ Attachment) cci Messrs. R.D. Martin J.T. Wheelock - INPO Records Center E.L. Blake W.M. Stevenson D.L. Wigginton NRC Resident Inspectors Office 9005240203 900521 PDR ADOCK 05000382 S PDC "AN B00AL OPPORTUNITY EMPLOYER"-

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At 2110 hours0.0244 days <br />0.586 hours <br />0.00349 weeks <br />8.02855e-4 months <br /> on April 20, 1990, with Waterford Steam Electric Station Unit 3 at 100% power, the condenser vacuum pump discharge wide range gas monitor (WRGM) effluent high alarm setpoint was discovered to be incorrectly set at 4.0E+6 microcuries/second vice 1.7E-1 microcuries/second contrary to Technical Specification 3.3.3.11. In November 1989, the effluent channel was converted from an accident monitor to an effluent release monitor and the high alarm was changed to 1.7E-1 microcuries/second, which if exceeded, causes the exhaust to be rerouted through charcoal filters to the Reactor Auxiliary Building Ventilation System.

This value was properly verified monthly between November 1989 and March 1990.

The incorrect value for the effluent high alarm was possibly entered during surveillance testing on March 24 or March 25 by either Health Physics or Instrumentation and Control Technicians. The incorrect setting was not found until April 20 due to an inadequate review of the completed surveillance procedures. The surveillance procedures are being reviewed for proper human factoring. The condenser vacuum pump discharge WRGM effluent alert alarm setpoint was correct and would have alerted operators before the high alarm setpoint was reached; therefore, the health and safety of the general public was not jeopardized during this event.

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010 0l2 0F 0l 5 At 2110 hours0.0244 days <br />0.586 hours <br />0.00349 weeks <br />8.02855e-4 months <br /> on April 20, 1990, with Waterford Steam Electric Station Unit 3 at 100% power, the condenser vacuum pump discharge wide range gas monitor (WRCM) ef fluent high alarm (EIIS Identifier IL-RA) setpoint was discovered by Health Physics (HP) technicians to be incorrectly set at 4.0E+6 microcuries/second vice 1.7E-1 microcuries/second during a monthly radiation monitor channel verification. This report is submitted as a condition prohibited by Technical Specification 3.3.3.11 in accordance with the requirements of 10CFR50.73(a)(2)(1).

In November 1989, the condenser vacuum pump discharge WRGM effluent channel vre converted from an accident monitor (E11S Identifier - MON) to an effluent release monitor and the high alarm setpoint was changed from 4.0E+6 microcuries/

second to 1.7E-1 microcuries/second. If this effluent high alarm is exceeded, the condenser exhaust pas is rerouted through charcoal filters to the Reactor

  • Auxiliary Building ventilation nystem. The setpoint change had been verified monthly during routine surveillance tests on the condenser vacuum pump discharge WRCM performed in accordance with procedure M1-3-386, " Condenser Vacuum Pump Discharge High Range Noble Gas Radiation Monitor Channel Functional Test." The last functional test that verified the correct effluent high alarm setpoint was conducted on March 14, 1990.

On March 25, a monthly administrative check of radiation monitor channel item '

setpointo was conducted in accordance with procedure HP-001-237 " Operation of the Radiation Monitor System." Documentation shows that the effluent high alarm setpoint was 4.0E46 microcuries/second, but no action was taken because of confusion over the required value. The radiation monitoring system (RMS)

(Ells Identifier - IL) data base manual referred to the setpoint as a floating point, meaning it was in scientific notation. The HP technicians misinterp?eted floating point to mean the value could change from time to time and did not further question the unexpected value. Administrative procedure, UNT-007-029,

" Control of the Radiation Monitor System Database Firmware" may have added to the confusion. When a change is entered to the RMS data base manual, the superseded page is not removed or annotated that a change exists. Therefore, ,

a technician is required to son through the RMS data base manual to verify  !

i the specific value is the most n , a. change )

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Ob ol3 0' Ol 5 a ,eo.ea.< w a eco w .onn Additionally, no maintenance was performed on the WRGM between March 14 and March 25. A functional test of the plant stack effluent accident WRGM was performed on March 24 by Instrumentation and Control (16C) technicians. The plant stack effluent accident high alarm setpoint is 4.0E+6 microcuries/second and the monitor used for the plant stack effluent accident WRGM surveillance is in close proximity to the condenser vacuum pump discharge WRGM monitor. An error during the performance of these procedures has been considered, but it is .

highly unlikely to have resulted in the incorrect high alarm value being mistakenly entered for the condenser vacuum pump discharge WRGM.

r On April 5, another functional test of the condenser vacuum putnp discharge WRGM was conducted by 160 technicians in accordance with procedure MI-3-386. The incorrect value of the effluent high alarm was noted at the beginning of the procedure. The correct value was entered and the computer printout used to verify values at completion of the test was annotated that,1.7E-1 microcuries/second was the value listed in the RMS data book. The effluent

  • high alarm was returned to 4.0E+6 microcuries/second at the coinpletion of the procedure by a different 16C technician due to confusion on the verification

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computer printout.

l j An incorrect value for the ef fluent high alarm for the condenser vacuum putup discharge WRGM was possibly entered during either'the administrative check of radiation monitor setpoints on March 25 or the functional check of the plant stack effluent accident WRGM on March 24. Interviews with the Up and 1&C 1

I technicians involved did not indicate that an incorrect high alarm setpoint was entered during these surveillance procedures. No system perturbations or j abnormalities occurred during this time period; therefore, it is highly unlikely for this one setpoint to change via a computer malfunction.

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The most probable root cause of this event is an inadequate change procedure for the RMS data base manual. The governing administrative procedure.

UNT-007-029, did not clearly denote changes to the RMS data base manual which may have provided confusion during functional testing or setpoint verification.

Contributing to the event are the following items:

- IIP technicians were inadequately trained on performance of HP-001-237,

" Operation of the Radiation Monitoring System" including the term floating point.

- Surveillance procedure, MI-3-386, is not human factored and is difficult to follow.

- There was an inadequate review of the completed procedures and

! therefore the incorrect setpoint was not discovered until April 20.. i There was an apparent procedural non-compliance during the performance of the functional test conducted April 5.

I Administrative procedure, UNT-007-029, is being revised to ensure superseded pages are annotated to climinate confusion when a change is entered and the

!. definition of floating point is being clarified. The revision should be completed by July 31, 1990. IIP technicians will be trained on procedure, lip-001-237, including proper conduct of setpoint verification and the definition ,

1 of floating point. This training should be completed by July 31, 1990.

Surveillance procedure, MI-3-386, will be revised to enhance human factoring by December 30, 1990. The personnel involved in the performance and review--

of the surveillance procedures have been counselled on procedural errors noted  ;

during the investigation. A supplement to this report will be submitted if any information develops to clearly show the root cause of this event. l 3

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Because the condenser vacuum pump discharge WRGM effluent alert alarm was correctly set at 1.03E-1 microcuries/second, and this alarm would have alerted operators to take immediate corrective action before activity levels reached the effluent high alarm setpoir t of 1.7E-1 microcuries/second, the health and l safety of the general public was not jeopardized during this event.  !

Similar Events Although no similar pro'.:lems have occurred with the condenser vacuum pump I discharge WRGM there was one case where incorrect setpoints were inserted in a radiation monitor. In March 1987, the gaseous waste management system (EIIS I

Identifier - WE) effluent radiation monitor alarm / trip setpoint was discovered ,

to be a factor of ten too high. This event was reported in LER-87-011. The  ;

root cause in this case was incorrect calculation of the alarm setpoints. The  !

technicians involved were counselled, t

Plant Contact t l W.T. LaBonte, Radiation Protection Superintendent. 504/464-3149, i r l-  ;

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