ML20043G711

LER 90-004-00:on 900521,personnel Error & FSAR Deviation Occurred & Resulted in Tech Spec Violation.Procedure 62CI-OCB-031-OS Incorrectly Directed Personnel to Periodically Open Airlock Doors.Memo issued.W/900615 Ltr

ML20043G711
Person / Time
Site:	Hatch
Issue date:	06/15/1990
From:	Hairston W, Tipps S GEORGIA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
HL-1140, LER-90-004-03, LER-90-4-3, NUDOCS 9006210044
Download: ML20043G711 (8)

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U.S. Nuclear Regulatory Commission ATTN: Document Control Desk -

Washington, D.C. 20555 t

PLANT HATCH - UNIT 2 NRC DOCKET 50-366 ,

OPERATING LICENSE NPF-5 LICENSEE EVENT REPORT PERSONNEL ERROR AND FSAR DEVIATION RESULT IN TECHNICAL SPECIFICATIONS VIOLATION .

Gentlemen:

3 In accordance with the requirements of 10 CFR 50.73(a)(2)(1), Georgia Power Company is . submitting the enclosed Licensee Event Report concerning personnel error and a FSAR deviation which resulted in (LER) a  ;

Technical Specifications violation. This event occurred at Plant Hatch -

Unit 2.

Sincerely, it] $b(

W. G. Hairston, III SRB /JKB/eb

Enclosure:

LER 50-366/1990-004 c: (See next page.)

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e U.S. Nuclear Regulatory Commission June 15, 1990 Page Two c: Georaia Power Comoany Mr. H. C. Nix, General Manager - Nuclear Plant Mr. J. D. Heidt, Manager Engineering and Licensing - Hatch GO-NORMS U.S. Nuclear Reaulatory Commission. Washinaton. D.C.

Mr. L. P. Crocker, Licensing Project Manager - Hatch U.S. Nuclear Reaulatory Commission. Reaion 11 Mr. S. D. Ebneter, Regional Administrator Senior Resident Inspector - Hatch j

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On 5/21/90, at approximately 1200 CDT, Unit 2 was in the Run mode at approximately 2436 CMWT (approximately 100% of rated thermal power). At that time, it was confirmed that procedure 62Cl-0CB-031-OS, " Aims Gamma Spectrometer Setup and Calibration," incorrectly directed personnel to periodically open both Post Accident Sampling System (PASS, Ells Code IP) room airlock doors simultaneously. This was included in a revision to the procedure which became effective on 9/11/89 and was intended to provide a measure of personnel safety while working with nitrogen in the PASS room. However, as confirmed by the Architect Engineer ( AE) on 5/21/90, opening both airlock doors to this room results in a breach of Unit 2 Secondary Containment (EIIS Code NH). Investigation showed that the direction to open both doors simultaneously had been added to the procedure in a way which violated established administrative controls and circumvented the safety review process. At the time the deficient condition was confirmed to exist, conservative measures had already been taken to prevent simultaneous opening of the doors.

The causes of the event are cognitive personnel error on the part of nonlicensed i personnel and a personnel airlock design which was not in compliance with FSAR  !

commitments, j i

Corrective actions include counseling of involved personnel, revising procedure  !

62CI-0CB-031-0S, issuing a management memo, installing interlocks on the Secondary Containment airlock doors, and modifying the nitrogen fill system.

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SUMMARY

OF EVENT j

On 5/21/90, at approxim-91v 1200 CDT, Unit 2 was in the Run mode at approximately .

2436 CMW (approximatelt Wot of rated thermal- power). At that time, it was 4 confirmed that procedure ,iu-0CB-031-0S, " Aims Gamma Spectrometer Setup and Calibration," incorrectly directed personnel to periodically open both Post Accident j Sampling System (PASS, EIIS Code IP) room airlock doors simultaneously. This was  !

included in a revision to the procedure which became effective on 9/11/89 and was 1 intended to provide a measure of personnel safety while working with nitrogen in the PASS room. However, as confirmed by the Architect Engineer (AE) on 5/21/90, opening ,

both airlock doors to this room results in a breach of Unit 2 Secondary Containment j (EIIS Code NH). Investigation showed that the direction to open both doors

• simultaneously had been added to the procedure in a way which violated established administrative controls and circumvented the safety review process. At the time the deficient condition was confirmed to exist, conservative measures had already been taken to prevent simultaneous opening of the doors. '

The causes of the event are cognitive personnel error on the part of nonlicensed -!

personnel and a personnel airlock design which was not in compliance with FSAR ~

comitments. l l

Corrective actions include counseling of involved personnel, revising procedure '

l 62CI-0CB-031-0S, issuing a management memo, installing interlocks on the Secondary  !

Containment airlock doors, and modifying the nitrogen fill' system.

DESCRIPTION OF EVENT l On 5/21/90, at approximately 1200 CDT, Unit 2 was in the Run mode at approximately {

2436 CMW (approximately 100% of rated thermal power). At that time, the AE, i responding to an inquiry made on 5/2/90, notified plant personnel that the '

simultaneous opening of both airlock doors to the PASS room, as stipulated in j procedure 62CI-0CB-031-0S, is a breach of Unit 2 Secondary Containment. The i procedure had cautioned plant personnel to ensure that habitability of the PASS room is maintained, while handling nitrogen in the room, by maintaining both airlock i doors = to the room in the open position.  ;

Typically, once per week a liquid nitrogen tank is transported into the PASS room in j

. order to fill a PASS Dewar flask. The Dewar flask, when filled with liquid nitrogen, provides cooling for a Germanium-Lithium crystal utilized in the PASS radiation detector. When filling the Dewar flask, an amount of gaseous nitrogen is discharged from the flask into the PASS room affecting oxygen levels and potentially affecting habitability of the room.

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. LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Aerzovio ove No aiso-oio4 IXPtRE S. 0 '31/0B F ACILITV hAME m DOCK 41 NUM0th (2) Lth NUMSER (6) PA04 (3) vi*a "W W  ?#3;'

PLANT HATCH, UNIT 2 o p lo jo jo ;3;6 l 6 9 l0 __ 0 ;0l4 0 [0 0 l3 or 0 l6 f tKT #1mo e spece e asev#est use espeonamC Fem 3154s(th The aforementioned caution was added during revision 1 of the procedure which became effective on 9/11/89. Subsequent to the revision, both doors were simultaneously opened once per week for approximately ten minutes each time. As identified by the AE, this constituted a breach of Unit 2 Secondary Containment which is in violation of the Unit 2 Technical Specifications section 3/4.6.5.1. Section 3/4.6.5.1 requires that Secondary Containment integrity be maintained (which includes maintaining at least one door in each airlock to the Unit 2 Secondary Containment closed) in conditions 1, 2, and 3, and wher, performing inservice hydrostatic or leak testing with the reactor coolant temperature above 212*F.

The potential for the simultaneous opening of both doors being a problem was first identified by nonlicensed personnel during closeout review of a PASS design change '

request. Further review of the situation was required to determine its impact on Secondary Containment. Specifically, the PASS room is not enveloped by the Reactor Building / Secondary Containment structure; instead, it is adjacent to the Unit 2 Reactor Building and is connected to Secondary Containment by a 16 inch diameter ventilation duct. Consequently, the affect that simultaneously opening both PASS room airlock doors had on Unit 2 Secondary Containment was not obvious and, therefore, the AE was contacted to evaluate the condition.

In the interim, conservative actions were taken to ensure that not more than one PASS room airlock door was open at a time. Specifically, the doors were locked on 5/2/90 and the keys controlled by chemistry supervision. Also, personnel responsible for performing procedure 62CI-0CB-031-0S were informed of the requirement to maintain at least one door in the PASS room airlock closed at all times in order to maintain Secondary Containment.

CAUSE OF THE EVENT One cause of the ev t it cognitive personnel error on the part of nonlicensed personnel . Persono i violated mcedure 10AC-MGR-003-OS, " Preparation and Control of Procedures," by ado. a .he h w  ; tion to procedure 62CI-0CB-031-0S after reviews of the procedure were i. %s , Huclear Safety and Compliance (NSC) and the Plant Review Board (PRB) tv au M-MGR-003-0S requires that proposed revisions to safety' related proe W u r r.wed for their impact on safety by NSC and the PRB prior to approval a.'- iOe aion. If, during typing of the procedure revision following the requir o ,c. J . , any minor errors or technical inconsistencies are identified, procedure 10AC-l0R-003-0S allows correction of the identified discrepancies with no additional reviews by NSC or PRB as long as the corrections obviously have no effect on safety and do not change the basic intent of the precedurc/ revision. In this event,= the caution in question was incorrectly added to the proposed revision after NSC and PRB reviews. The individual responsible for the revision (the procedure sponsor) misunderstood procedure 10AC-MGR-003-0S, believing that changes to the procedure could be made following said reviews so long as the intent of the procedure / revision was not affected by the change. Had the required reviews not been circumvented, it's likely the opening of both airlock doors would have been questioned and the event avoided, i

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0 10 0 14 oF Ol6 rem , - . - - =c w as w im Another cause of the event is less than adequate design of the PASS room airlock. The Unit 2 Final Safety Analysis Report (FSAR) states that for personnel airlocks that are a part of the Secondary Containment boundary the doors are mechanically interlocked preventing simultaneous opening of the doors and, thus, a breach of Secondary Containment. However, in this event, the U.SS room airlock doors were not provided with mechanical interlocks thus allowing the simultaneous opening of the doors.

A contributing factcc ta tht a event is less than adequate the design of the Dewar flask / liquid nitregw fill system. The system is designed such that filling activities i can be performeti rarely, that is, ouM Ge of the PASS room. In this mode of filling, personnel do not have to enter the PASS rosa $:o prform the activity and, thus, are not l' subjected to a potentially harmful atmosphere. However, because of the system's piping configuration, remote filling is a very inefficient method requiring excessive amounts of liquid nitrogen and involving an extensive amount of time to complete.

Consequently, chemistry personnel typically forego remote filling and enter the PASS room to locally fill the Dewar flask. This introduces a potential personnel safety hazard into the filling activity. Had the remote fill system been differently designed, local filling of the ficsk would not have been needed; it then would not have '

been necessary to simultaneously open both PASS room doors and to revise procedure i 62CI-0CB-031-0S to allow this.

h REPORTABILITY ANALYSIS AND SAFETY ASSESSMENT This event is reportable because an approved procedure directed personnel to breach Unit 2 Secondary Containment contrary to Unit 2 Technical Specifications section 3/4.6.5.1 and resulted in actual breaches in secondary containment. This is an operation prohibited by the Technical Specifications and, therefore, is reportable

• under 10 CFR 50.73(a)(2)(1)(B).

Although the event is reportable, it posed no serious threat to nuclear safety. This is because the probability of having an accident requiring the Unit 2 reactor building period that the doors were open, is secondary _ containment insignificantly small (on the during order ofthe 10-obrief timg/yr.)

Secondary Containment is designed to minimize any ground level releases of radioactive material which may result in the unlikely event of a design basis accident. The

~ Secondary Containment System consists of the Standby Gas Treatment System (SGTS, EIIS Code BH), the Main-Stack, and the Secondary Containment boundary (i.e., the Reactor Building). The SGTS functions to maintain the Reactor Building at subatmospheric pressure and to filter releases to the environment. The Rain Stack provides an elevated release path for discharges to the environment. The Reactor Building provides  ;

a secondary containment boundary for the reactor. It is designed such that the leakage

.into Secondary Containment will not prevent SGTS from maintaining Secondary Containment at a minimum vacuum of 0.25 inches of water. One of the design features of the Reactor Building.is personnel airlocks which provide ingress and egress to Secondary Containment without breaching the containment boundary.

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.The safety significance of this breach of secondary containment has been estimated using probablistic methods. In the event, the airlock doors were simultaneously opened ,

once per week, approximately 10 minutes each time, each week between 8/30/89 and 5/2/90 (approximately 35 weeks). Based on this data and normalizing over a one year period, the probability of thq doors being simultaneously open at any point in time is approximately 7 X 10-4/ year. Accidents of concern are core damage events that cause significant core melt / damage and release to the reactor building within approximately 10 minutes. Using the results of a representative BWR plant in NUREG-1150, the cumulative core damage frequency (CDF) from a LOCA with core damagg or an anticipated ,

transient without scram (ATWS) with core damage is about 2.2 X 10-0/yr. Multiplying the probability f having the doors open and having one of these two types of accidents is about 2 X 10 g/yr and not of safety significance. Even using the total NUREG-1150 CDF for internal and external events of about 1 X 10-4/yr, leads to an acceptable low .;

probability of about 8x10-U/yr. (Based on section 3.2.3 of American National -

Standard ANSI /ANS 52.1-1983, " Nuclear Safety Criteria for the Design of Stationary Boiling Water Reactors," an event with a probability of occurrence of less than 1 X 10-6 is not a credible event and shall not be considered for design.) Therefore, opening of the air lock doors posed no significant threat to nuclear safety.

CORRECTIVE ACTIONS  ;

Corrective actions for this event include the following:

1. The PASS room airlock doors were locked on 5/2/90 and the keys were controlled by chemistry supervision.

2. Personnel performing the liquid nitrogen filling of the Dewar flask and those _1 responsible for chemistry surveillances on the PASS were informed of the necessity ,

to maintain at least one door of the PASS room airlock in the closed position.

3. . Procedure 62CI-0CB-031-0S has been revised to remove the provision which allowed 1 simultaneous opening of the airlock doors and to add a requirement for maintaining at least one airlock door closed. The procedure revision was made effective on 6/8/90.

4. Mechanical interlocks will be installed on the doors to prohibit simultaneous opening of the airlock doors. The interlocks will be installed by 6/1/91.  :

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5. A Management Memo will be issued to emphasize to procedure sponsors the importance i of understanding and complying with the established controls for processing procedure revisions. The memo will be issued by 6/29/90.

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6. The remote fill system has been modified to provide more efficient filling of the Dewar flask precluding the need to perform the fill locally.

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ADDITIONAL INFCS.MATION  !

l.. No systems other than Secondary Containment were affected by this event.  ;

2. No previous similar events have occurred-in which a failure to comply with -

administrative controls regarding procedure processing resulted in a condition prohibited by the plant Technical Specifications. j t

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