ML20043E451
| ML20043E451 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 06/07/1990 |
| From: | William Cahill, Hood D TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LER-90-012, LER-90-12, TXX-90184, NUDOCS 9006130010 | |
| Download: ML20043E451 (9) | |
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r C 909.4 nlELECTRIC Ref # 50 73 50.73(a)(2)(i) wjcf",,,,,g,,, June 7, 1990 U. S. Nuclear Regulatory Commission Attn: Document Control Desk
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Washington, D. C. 120555-
SUBJECT:
COMANCHE. PEAK STEAM ELECTRIC STATION DOCKET NO. 50-445 DEVIATION-FROM-TECHNICAL SPECIFICATION LICENSEE EVENT REPORT 90-012-00 i .
Gentlemen:
2 Enclosed is Licensee Event Report 90-012-000 for Comanche Peak Steam Electric-Station-Unit 1,'" Time Limits of Technical Specification Action Statement Exceeded Due to Personnel Error."
Sincerely, I
William J. Cahill, Jr.
= DEN /daj 3
Enclosure c - Mr. R. D. Martin, Region IV
- Resident Inspectors, CPSES (3) 9006130010 900607 i PDR ADOCK 05000445 s PDC
-- 400 North Ohve Street LB 81 Dallas, Texas 73201
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, Encloaur@ to TXX 90184 NRC FORM 366 U.S. NUCLE AR REOULATORY COMWSSON APPROWD OMB NO. 3M0104 EXPIRE 8:4.'3392 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATON COLLECTON REQUEST: 60.0 HRS. FORWARD COMMENTS REGARDtNO
'VR EN ESTlWATE T THE RECOR S AN REP RTS MANA EWENT LICENSEE EVENT REPORT (LER) 8 RANCH (P-630) U.S. NUCLEAR REQULATORY COWWtSSON WASHINGTON.
3C. 20555, ANO TO THE PAPERWORK REDUCTON PROJECT (3%C104).
OFFICE OF MANAGEMENT ANO BUDGET, WASHINGTON. DC. 20603.
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On May 8,1990, with the plant at 45% power, Control Room personnel failed to satisfy the time limit for completion of action required by plant Technical Specifications related to plant radiation monitoring. As a result of a series of miscommunications between the System Engineer, Radiation Protection personnel, and Operation's personnel, one channel of Control Room air intake radiation monitoring was removed from service without authorization from Operations personnel. When notified of the out of service monitor, Control Room personnel failed to complete the Technical Specification action requirements in a timely manner. T;1e cause of the reportable event was personnel error resulting from failure to appreciate the significance of information provided. Corrective actions included individual counseling and revision of administrative procedures.
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- 1. DESCRIPTION OF THE REPORTABLE EVENT A. PLANT OPERATING CONDITIONS BEFORE THE EVENT On May 8,1990, at 1140 CDT Comanche Peak Steam Electric Station (CPSES) Unit l 1 was in Mode 1, Power Operation, with reactor power at 45 percent. l B. STATUS OF STRUCTURES, SYSTEMS OR COMPONENTS THAT WERE INOPERABLE AT THE START OF THE EVENT AND THAT CONTRIBUTED TO THE EVENT One channel of Contro! Room air Intake radiation monitoring (Ells:(MON)(IL)) was ;
inoperable at the ume of the event; however, this component did not contribute ;
directly to the event.
C. EVENT CLASSIFICATION Any operation prohibited by the plant's Technical Specifications.
D. NARRATIVE
SUMMARY
OF THE EVENT INCLUDING DATES AND APPROXIMATE TIMES On May 8,1990, at approximately 1000 CDT the System Engineer (utility, non-licensed) for the Digital Radiation Monitoring System (DRkS) was notified by Operations that one channel of Control Room air intake radiation monitoring was reading erratically. The System Engineer prepared the docun:ents procedurally required to modify the DRMS database to remove the monitor frem service for troubleshooting and repair. In the Control Room the Shift Technicai Advisor (STA)-
(utility, licensed), who had authority to authorize work activities, informed the System Engineer that a Digital Channel Operational Test (DCOT) was being performed on ,
two other channels of Control Room air intake radiation monitoring and declined to remove the erratic monitor from service. Because of the testing activities in progress at the time, both trains of the Control Room Air Conditioning System (CRACS)
(Ells:(VI)) were in the Emergency Recirculation Mode to satisfy the requirements of Technical Specification 3.3.3.1, RADIATION MONITORING FOR PLANT OPERATIONS. A series of miscommunications between the System Engineer, Radiation Protection personnel, and Operations personnel resulted in the erratic
. . Enclosure to TXX 90184 NRC FORM 366A ' U.S. NUCLEAR REGULATORY COMMISSION APPROVED OWS NO. 31940104 ESTNATED SURDEN PER RES COMPLY NTH THE INr,,,y4ho, LICENSEE EVENT REPORT (LER) gc,' ",,"',g*,'; ,' l","ggo",*,'"o O'l," fog TEXT CONTINUATION 'g li g ,%8 @ j,' 'g ' & o","',OoW Q OFFICC OF WANAGEWENT AND BUDGET WASHINGT.IN,DC,304 Page (3)
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- 1. m . - . . . NRc orm = A. m n monitor being removed from service by a Radiation Protection (RP) technician (utility, non licensed) at 1125 CDT without the knowledge of the STA. After removing the radiation monitor from service, the RP technician informed the Shift Supervisor (utility, licensed) in accordance with procedural requirements and the Shift .
Supervisor conveyed the information to the STA. However, because of his recent discussion with the System Engineer, the STA was confident that the monitor had not actually been removed from service, and did not verify the status of the monitor. At 1142 CDT, following completion of the DCOT, the CRACS was placed in the Normal Operating Mode with Train A running and Train B in Standby. At approximately 1230 CDT an Instrumentation & Control (l&C) technician (utility, non-licensed) Informed the STA that the monitor had been removed from service. The STA checked the status of the monitor and verified that it had been removed from service. At approximately 1405 CDT the STA initiated a Limiting Condition for Operation Action Requirement, and at 1410 the Reactor Operator (utility, licensed) placed the CRACS in the Emergency Recirculation Mode with Train B running and Train A in Standby.
The time taken to initiate this action exceeded the one hour limit of Technical Specification 3.3.3.1.
E. THE METHOD OF DISCOVERY OF EACH COMPONENT OR SYSTEM FAILURE OR PROCEDURAL OR PERSONNEL ERROR At approximately 1230 CDT, while authorizing additional testing on the DRMS, the STA was Informed by an I&C technician that the monitor had been removed from service. The STA checked the monitor status and confirmed that it was off line. At
- 3pproximately 1405 CDT the STA checked Technical Specification 3/4.3.3.1 and realized that the time limit for taking action in response to an inoperable radiation monitor had been exceeded.
II.. COI APONENT OR SYSTEM FAILURES A. FAILED COMPONENT INFORMATION Not applicable - there were no component failures which contributed directly to this event.
, En' closure to TXX 90184 NRO FORW 3e6A ~ U.S. NUCLE AR REQULATORY COWWSSON APPROVED OWS NO. 31640101 GSTlWATED BURDEN PER RES Y WITH THS PFORMATON LICENSEE EVENT REPORT (LER) go'l,'t,",ET*,'; ,T","*g,7,^$ M,8
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B. FAILURE MODE, MECHANISM, AND EFFECT OF EACH FAILED COMPONENT ;
Not applicable - there were no component failures which contributed directly to this I event.
C. CAUSE OF EACH COMPONENT OR SYSTEM FAILURE Not applicable - there were no compc.1ent failures which contributed directly to this event.
D. SYSTEMS OR SECONDARY FUNCTIONS THAT WERE AFFECTED BY FAILURES OF COMPONENTS WITH MULTIPLE FUNCTIONS Not applicable - there were no component failures which contributed directly to this event.
Ill. ANALYSIS.0F THE EVENT ,
A. SAFETY SYSTEM RESPONSES THAT OCCURRED Not applicable - there were no safety systems required to respond during this event.
B. DURATION OF SAFETY SYST EM INOPERABILITY There were no systems rendered incapable of performing their intended safety functions during this event. Redundant Control Room air intake radiation monitoring was not available for one train of CRACS for greater than the one hour Technical Specification limit.
C.- SAFETY f GNSEQUENCES AND IMPLICATIONS OF THE EVENT The CRACS provides radiation protection to permit access and occupancy of the Control Room complex under accident conditions, without personnel receiving radiation exposure in excess of the limits of 10CFR50, Appendix A, General Design Criteria (GDC) 19. This is accomplished through the use of redundant channels of radiation monitoring for each of the two Control Room air intake flow paths. Sufficient
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Olo 0I5 OF 017 wm,. - . %. ,. NRc F , m.m n redundancy is maintained to permit a channel to be out of service for testing or maintenance while still ensuring that the Engineered Safety Feature (ESF) actuation-function will be initiated when the radiation level _ monitored by the system reaches the setpoint. At no time during this event was the ability of the CRACS ESF function 3 disabled because either the system was in its accident configuration or a sufficient number of operable monitors were in service to assure system actuation. The CRACS remained fully functional and capable of performing its intended function in t response to any of the accident conditions for which it was designed, it is therefore concluded that this event did not adversely affect the safe operation of CPSES Unit 1 - "
or the health and safety of the public.
IV. CAUSE OF THE EVENT Root Cause <
The cause of the event is personnel error resulting from failure to appreciate the significance of information provided.
Contributorv Factors ;
A number of factors have been identified which contributed to the less-than-adequate personnel performance; and while no single factor can be considered to have caused the event, the cumulative effect of the combination of influences from the various contributing factors was sufficient to present an obstacle to effective task performance.
- 1. One contributory factor is considered to be deviation from the expected sequence of steps. Prior to the performance of testing or maintenance activities on components with Technical Specification action requirements, the typical sequence of events provides an opportunity for the individual authorizing the activity to review the Technical Specification requirement and prepare the appropriate documents prior to performance of the activity. In this event, the normal process was circumvented and the most convenient opportunity for review of the related Technical Specification was missed when the component was removed from service without the knowledge of Operations personnel.
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L , En' closure to TXX 90184 NRC FORM 3e6A - U.S. hW'AE A 9 REOutATORY COM MISSON APPROWD OMG NOM 0W ESilMATED BURDEN PER RES COWplY WITH THIS INFORMATION LICENSEE EVENT REPORT (LER) " ',C'y,1 o, 3 8'; ,'l"a*g,y
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- 2. An additional contributory f actor is considered to be less than adequate verbal communication. The Radiation Protection Supervisor and the System Engineer did not effectively communicate the information from Operations personnel prior to removing the monitor from service. Specifically, the RP Supervisor thought the System Engineer would solicit the approval from Operations to remove the monitor from service while the System Engineer intended to discuss only the Technical Specification requirements associated with the removal and had no reason to discuss the "approvai" since RP would be the group removing the monitor from service.
V. CORRECTIVE ACTIONS Root Cause Failure to appreciate the significance of information provided.
Corrective Action Individual counseling was administered to emphasize the importance of timely compliance with Technical Specifications.
Contributorv Factor - 1 Deviation from expected sequence of events.
Corrective Action A rr emorandum was issued to all RP personnel with DRMS responsibilities describing thle event and directing RP personnel to clearly communicate the details of changes to the DF MS with Operat!ons personnel prior to making those changes, in addition, actions taken on previously identified human factors considerations should provide useful information to personnel performing testing or maintenance on radiation monitoring channels. Placards have been placed on the DRMS panel clearly denoting which chanriels have associated Technical Specification or Offsite Dose Calculation Manual requirements. Placards have been placed on the Control Room air intake radiation monitor control panel clearly denoting which monitoring channels are associated with each of the two Control Room air intakes.
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. ErIclosure to TXX-90184:
NRC FORM 200A- u s.% CLEAR REOULATORY COMMIS810N APPROVED OM9 NO. 31940:04 EMPIRE 5:44099 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH TH18 lNFORMATON NECTION RNSTt 6MHR FORWAm MMMM REGAWM LICENSEE EVENT REPORT (LER) SURDEN EtflMATE TO THE RECORDS AND REPORTS MANAGEMENT TEXT CONTINUATION ""^""7*"*""^""'"""""***"*^*""".
0C. 20656, AND TO THE PAPERWORK REDUCTION PROJECT (31640104)
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COMANCHE PEAK - UNIT 1 015101010l414l5 910 -
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- Contributorv Factor - 2 ,
Less-than adequate verbal communication.
Corrective Action i i
The procedure specifying administrative control over the DRMS will be revised to 1 enhance communication between RP and Operations personnel, and to ensure that the .
operability status of affected channels is determined prior to a database change. l 1
VI. PREVIOUS SIMILAR EVENTS 1 There have been no previous similar events reported pursuant to 10CFR50.73.
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.' , M BY SUBJEDT DOCKETED W. G. Counsil 19BT J. Ellis (CASE) (FC)
L'. D. Nace LN1
' F. A. Camp BT21 N. D. Spence / 31ST ghusses45pfffPP5fP89FB J. L. Vota (FC)
J. F. Streeter GEmegmegegggna449Me$ N. S. Reynolds (FC)
W. J. Cahill E22 400am L. Kennedy (FC) eggugganggye006 R. D. Walker / 24ST 3.DM J. S. Marshall B - ' - " ^ ^ - - " - ' ' ~
J. E. Krechting 24ST emmesmDusetsuSBB4 W. G. Guldemond CL1 - ^ - " abstemaet R. A. Wooldridge 32BT A. B. Scott 010 R. M. Fillmore 32BT J. J. Kelley 009 C_PSES 1R & RESPONSES T. M. Wilson (FC) M. R. Blevins 009 J. L. French RT1 M. J. Riggs (IOER) T03 89pupppgNuS8D R. L. Ramsey 16BT 1 N. C. Schmidt 24ST D. N. Hood 1be> O O 6, TXX File (Corp.) ST24 T. Sprinkle 21BT TXX File (Site) CL1 J. J. Allen 011 TXX File (Bethesda) (FC)
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10ER - Correspondence which pertains to 10ER program (e.g., generic
' letters. NRC information notices. NRC bulletins. etc.) and CPSES Inspection Reports.
CASE - All filings and correspondence between the NRC staff and TU Electric.
_: ORC - All SDAR's. LER's. CPSES Inspection Reports and responses. NRC Bulletins and responses and Generic Letters and responses, and description letters for changes to licensing bases documents.
ISEG - All 10ER material plus inspection reports for TV Electric and other plants.
May 22, 1990
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