ML20043C674

LER 90-006-00:on 900502,review of Effluent Sample Analysis Revealed That Turbine Bldg Ventilation Exhaust Had Not Been Analyzed Exceeding Time Limit.Caused by Personnel Error. Training & Counseling conducted.W/900601 Ltr

ML20043C674
Person / Time
Site:	Grand Gulf
Issue date:	06/01/1990
From:	Byrd R, Cottle W SYSTEM ENERGY RESOURCES, INC.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
AECM-90-0101, AECM-90-101, LER-90-006, LER-90-6, NUDOCS 9006060036
Download: ML20043C674 (6)

Text

. .. . . _ . . . _

4

/

O w System g=gru

, Energy muxmsmo ite 601437 N109 William T. Cottle Voe Pmooent June 1, 1990 " '"0"*""$

U.S. Nuclear Regulatory Commission Mail Station P1-137 Washington, D.C. 20555 Attention: Document Control peak Centlement

SUBJECT:

Grand Gulf Nuclear Station Unit 1 Docket No. 50-416 License No. NPF-29 Effluent Sample Analysis Exceeds Time Limit Due to Personnel Error LER 90-006 AECM-90/0101 Attached is Licensee Lvent Report (LER)90-006 which is a final report.

Yourn truly, DVW WTC cg Attachment cca Mr. D. C. Hintz (w/a)

Mr. T. H. Cloninger (w/a)

Mr. R. B. McGehee (w/a)

Mr. N. S. Reynolds (w/a)

Mr. H. L. Thomas (w/o)

Mr. H. O. Christensen (w/a)

Mr. Stewart D. Ebneter (w/a)

Regional Administrator U.S. Nuclear Regulatory Commission Region II 101 Marietta St., N.W., Suite 2900 Atlanta, Georgia 30323 Mr. L. L. Kintner, Project Manager (w/a)

Office of Nuclear Reactor Regulation U.S. Nuclear Regulatory Commission Hall Stop 14B20 4

Washington, D.C. 20555 / V 9006060036 900601 '

DOC - 1 PDR ADOCK 05000416 / \

6 PDC

A t t n e t im ,, n t- en A t r'u o n / n i n i sent perm 20 v5 seuCLl u atoukatORY COaAMietsoe

• APPAOVID Dest NO 311001M E ' at ' ' ' O UCENSEE EVENT REPORT (uiR) )

l DOCatt Nuestam ut FAGE iT

' ACILity tenest of Crand Gulf Nuclear Station -

Unit 1 0 l5 ! 0101014 11 16 tlorl0l5_

f i t L 4 4.s Effluent Sample Analysis Exceeds Time Limit Due To Personnt Error EVINT Datt 191 LimNUMeta m alPOnt Daf t (71 OTHta f ACILif elt INVOLVED ISI 3

• • " Dockti muMetsusi MONTM Dav vt A6% v4AR "' 'M MONTM OAV vtAR C't v haws e NA 0l5l010tol l _ l

~ ~

O! 5 O! 2 9 0 9l 0 0l 0l 6 0 l0 0l 6 0l1 9h 0 i 5 to i 0 i 0 l t inis atront is sueMrtiso PunsuaNT to tut atauimeMtNis Op to con g ten =a e=e er =re e sone we..aes ott

== t = 1 . n. nl.lan .

nn.

nnm m a mmu eoamm ennomm g _

a.mmm

. nman.M [

n.1 0, si 0 _ _

. n.,mi..n Ai g,N3,.

g,;.,.g;;,,

. mnnm a nl.imni n .. Inn i u n.,mm o n .lan..n.1

""" ~~

so .emmn n.i se nmane so nman.i Voluntary Repor-LICl'dSit CONT ACT POR THl3 Lim (121 tt LEPHONE NUM9in N1MB anta CCOt unnnld tJ . Byrd/Licensine Encineer 61011 4 l 3 l 7 l- 1211 l 8 l' 2 COMPLitt ONE LINE FOR L ACM COMPONENT F AILumt DitCalttD IN THIS mtPOnt Hal R ' ' ""

Cault 8v8ttu COMPONINT "'j'ggC 0 Pm$8 Caust $vsttM COMPONENT $0' "fD "mI P

s I i l 1 I i i t i i i l i i l 1 l l l I 1 l l l 1 1 l l SUPPLEMENT AL REPont tMPGCit0 liel MONTM DAY YtAm SVOMi&SION Y E S 110 ren temp'en iJn9tCTED GUOMIS$10N CA TEl NO l l l Auf n ACT a,- M em . , . . .,,r..-.,c, a, .y. .,u, er -,.. . , n ei

('

r On May 2, 1990, a review of a gaseous offluent sample analysis revcaled that the Turbine Bullding Ventilation (TBV) exhaust rample obtained on April 18, 1990 had not been analyzed within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> as r., quired by notation "C" of Technical Specification Table 4.11.2.1.2-1. The Radwaste Building Ventilation (RWBV) exhaust filter was analyzed t sico; once lapeled properly as the "RWBV" filter and again incorrectly labrlod as the "TBV" filter. As a result, the TBV filter was not analyzed t.ntil discovery of the situation on May 2. The conditions of the Limiting Condition for Operation and its associated action statement were met at all times.

The failure to analyze the TBV sample within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> was caused by personnel error due to inattention to detail and a lack of a proper l self-verification. Training and counseling of appropriate Chemistry personnel in being conducted.

L L ac, f orm att . L4LM V V b

Attachment to AECM-90/0101

• g' men va aweaan noeucavear -

• UCENSEE EVENT REPORT (LER) TEXT CINTINUATION awaoven o=e =o on-o*

enames twee paestrTv nesse m escast asuomen et paes is 6sa mummen e veam usagl',A6 .

Pegg nennd nulf Nuclent Statlen 0l8l0l0l9h 1116 4C -

01016 -

01 0 012 0F Ol5 vert e a a ensame anc e== manwim _

A. Reportable Occurrence On May 2, 1990 a review cf e gr.coous effluent sample analysis revealed that a Turbine Building Ventilation (EIIS system code: VK) exhaust sample had not been analyzed within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> after removal as required by notation "C" of Technical Specification Table 4.11.2.1.2-1. Since the conditions of Limiting Condition for Operation (LCO) 3.11.2.1 and its associated action statement were met, the situation is not considered to be an operation or condition prohibited by the Technical Specifications and,' therefore, is not reportable pursuant to 10CFR50.72 nor 10CFR50.73. We believe this position to be consistent with the guidance provided in NUREG 1022, Supplement 1. This report is submitted as a voluntary report.

B. Initial Conditions The plant was operating,at approximately 80 percent power at the time j of, discovery.

l C. Description of Occurrence Technical Specification Table 4.11.2.1.2-1 establishes a radioactive gaseous effluent sampling and analysis program to ensure that the dose rate due to radioactive materials in gaseous effluents from the site to 1 areas at and beyond the site boundary remains less than the limits of Technical Specification 3.11.2.1. As part of this program, ventilation exhaust samples are removed weekly, counted, and analyzod for I-131, '

1-133, and other principal gamma emitters. Each sample consist of-a charcoal cartridge and a particulate filter. Note'"C" of Table 4.11.2.1.2-1 requires the analysis to be performed within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> of removing the samples.

j On April 18, 1990, samples were removed from the four building ventilation exhaust monitors for the above surveillance. The filters and charcoal cartridges were counted and analyzed onr ipril 19,.1990.

The results were confirmed to be less than Technical Sps. ification i limits and the completed surveillance was approved as acceptable, g . as l LER9006 1

Attachment to AECM-90/0101 see a==> man va mus6 san aneu6arent sammes.

, , UCEN83E EVENT REPORT (LER) TEXT CONTINUATION aaaovec ome .a mes-em

. anoines. ersus ,

ease 6:n maass m seenet muussa ei 6en smassen a wm vsan -

!E','6 m ;7M Grand Gulf Nuclear S :ation oislolol#141115 9l 0 -

01d 6 - O lo 013 OP O 15 verrn ==a = .em amea aenm m ,

on May 2, a Chemistry specialist compling the data noted that the surveillance data for the Radwaste Building Ventilation (RWBV) exhaust-filter and that for the Turbine Building Ventilation (TBV) exhaust filter were the saue. An investigation was conducted which concluded that the RWBV filter had been analyzed twice. One analysis was properly labeled as the "RWBV" filter; the other analysis was

. incorrectly labeled as the "TBV" filter. As a result, the TBV filter.

was not counted nor analyzed.

Upon discovery of the error, the TBV filter was retrieved from storage and analyzed in accordance with the Offsite Dose Calculations Manual (ODCM) utilizing half-life data to compensate for the longer decay time. The effect of the longer decay time was insignificant.

D. Apparent Cause The missed TBV filter analysis was due to a computer entry error which h incorrectly identified the RWBV filter analysis as the "TBV" filter analysis. The computer operator erred primarily due to inattention to }

i detail and lack of a self-verification.

The analysis is performed utilizing a Germanium Counting and Computer.

system. Each sample is removed from its holder assembly and placed in  !

a Petri-dish that is labeled to identify the specific sample. 'After a specified decay time, the petri-dish containing the sample is.placed in a detector for counting and analysis. The identification of the sample is manually entered into the computer._ The identification also appears on the completed analysis data sheet printed from the computer program. '

4 When the analysis of the RWBV filter began, the' sample was incorrectly entered into the computer as the "TBV" filter. Another individual assigned to continue the surveillance noted that the RWBV filter sample o in the detector did not match the computer identification. This (

individual corrected the computer identification and performed the '

analysis again believing that the TBV filter analysis had already been completed. As a result, the RWBV filter was analyzed twice and the TBV. ,

filter was missed. The surveillance package included a completed data sheet for each RWBV filter analysis; one properly labeled and one incorrectly labeled as the "TBV" filter analysis, s

i i

g .--

LER9006 i.

', Attachment to AECH-00/0101

. . . .ae_ .= =

- LICENSEE EVENT REPORT (LER) TEXT CONTINUATmN aaaoveo ow a n-**

sp ees s w a receuftease m Deeelft soutett m gg.seuses. e P I ID -

.... =tmS ~ ~"Eit:

Grand Gulf Nuclear Station q4 olsjojojel4l1 6- 9l0 -

0l0l6 -

0 l0 o7,0 l5 vert n . = .sm anc a en wim .

=

A previous event of personnel error affecting performance of this surveillance was reported in LER 89-011. In that incident, personnel J installed an empty sample holder assembly in the Fuel llandling Area Ventilation System. As a result, the sample holders were modified and labeled for easier identification and the procedure was changed to -

require a documented inspection of the sample assembly prior to installation. Those corrective actions addressed the concerns -

associated with sample holder identification. An overall review of the 1

Chemistry program was conducted, but the particular situation of- J incorrectly identifying a sample filter during analysis was not

• perceived.

E. Supplemental Corrective Actions An Incident Review Board convened on May 3, 1990 to investigate the incident. A Human Performance Enhancement System (llPES) evaluation was also conducted. The following correctivo actions have been completed or are planned to preclude recurrence.

o Chemistry personnel involved in this event were counsoled by the Chemistry Superintendent. '

o All applicable Chemistry personnel were informed of the event and the fundamental causes of the situation; i.e., inattention to detail and lack of self-verification.

o Mootings were held with all Chemistry shift supervisors to i discuss the event and stress the practico of self-verification.

o Additional training will be conducted which will include the -

expectations of personnel performing such tasks, the particular '

olomonts of a detailed data packago review, and the proper actions that should be taken whenever errors or uncertainties =

are identified, e

o The computer program will be ovaluated to dotormine if 1 enhancements can be made relative to sample title entries. -

All actions are expected to be completed by July 3, 1990.

m M

LER9006

. Attachment to AECM-90/0101

. lent ena n euesana a n u m onv eamm

.' - . UCENSEE EVENT REPORT (LAR) TEXT CONTINUATION m ovie one =o v a-e *

. ex ines e m e 5451487V Ite03 til teamet seuesta th Lea anagea em Past tai weae -H Q h4 " d*,"

Crand Gulf Nuclear Station 0 l6 l 0 l 0 l 0 la 11 16 oln -

nlnlA -

n In 0 15 0F 0l5 ten n ==. === a meses .mmmw asc a== man w im .

F. Safo*Ly Assessment The weekly samples are stored in the labeled Petrl-dishes pending completion of quarterly analyses. The TBV sample was readily retrieved, counted, and analyzed with results quite different from that of the other samples.

The renults of the TBV sample analysis confirmed that no Technical f; pts it Acation limits were exceeded. The effect of the longer decay tun was insignificant, but was compensated for in accordance with the methodology of the ODCM.

g .... a.

LER9006

_ _ . . . . . - . _ , . . . . . . . ..