ML20043H295

LER 90-007-00:on 900516,discovered That Actions Taken for Inoperable Reactor Water Level Transmitter Not Adequate to Comply W/Requirements for Tech Spec 3.3.2.Caused by Personnel Error.Meetings Held w/personnel.W/900615 Ltr

ML20043H295
Person / Time
Site:	Grand Gulf
Issue date:	06/15/1990
From:	Byrd R, Cottle W ENTERGY OPERATIONS, INC.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
AECM-90-0109, AECM-90-109, LER-90-007, LER-90-7, NUDOCS 9006250066
Download: ML20043H295 (5)

Text

F 1

.g Entergy

. gyg"c== ia=-

6peratons m = Jus =

Tu 6D14374:09 W. T. Cottle m n, s .y June 15, 1990 m-a '

O.S. Nuclear Regulatory Commission I Mail Station P1-137 -

Washington, D.C. 20555 l Attention: Document Control Desk Gentlemen:

SUBJECT:

Grand Gulf Nuclear Station Unit 1 Docket No. 50-416  :

License No. NPF-29 Failure To Comply With Technical Specifications Due To Personnel Error -

LER 90-007 AECH-90/0109 Attached is Licensee Event Report (LER)90-007 which is a final '

report.

Yours truly, ,

WTC:cg "IO Attachment cc:

Mr. T.D.

Mr. H. C.

Cloninger Hintz(w(w/a) /a)

Mr. J. G. Cesare (w/o) i Mr. R. B. McGehee (w/a)-

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

Mr.H.H.

Mr. O. L.

ChristensenThomas (w/o)(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, Secrgia 30323 Mr. L. L. Kintner, Project Manager (w/a) l OfficeofNuclearReactorRegulation l U.S. Nuclear Regulatory Commission Mail Stop 11021 / p Washington, D~.C. 20555 /

LER90007/SCMPFLR - 1 gg62ggggggggggg16 5 PDC

. a AttechmInt to AECM-90/0109

,e esRC Pow 3 Des W 6 NUCLE AR ROOULATORY COGAbilme08s APP 810vt0 OMS NC 31#4108

. UCENSEE EVENT REPORT (LER) '*'"'8""

i eAciuTY NAME ni poCRt? NUMetR Gi rain m I Grand Gulf Nuclear Station - Unit 1 0 ls l 0 j 010161116 1 l0Fl O l 4 18768 44:

Failure to Comt,1v Vit_h Technical Stiecifications Due to Personnel Error EVENT DAf t tli Lth NUMSERlei REPORT DATE (76 OTHER f ACILITill INvotvt0108 MONY ?AY YEAR YEAR L MONTH DAY YEAR F ACibet v hawlt DOCkti NVM9tRtSt ku#N[R v ,

NA 0l5l0 1 0l0] l l

~ ~

O!$ 1l6 9 0 9l0 0 l0 l 7 0 l0 0 l6 1l5 9l 0 0 1 5 l 010 1 0l l 1 opt RATisse THIS RSPORT 68 WOMITTED PURSUANT TO THE REQUIREM6NTS Of 10 CpR O tenece one er n*ere of rae f.newal HH j l N 40116) 20 408tel to.736slGHwi 73.71thi R 30.eseteH1Hil to 304eHil to.73telGHet 73.? Hal n.i u oi n a wnHai

= =.Hei amH:Hv.i _ =ggg,_

Jesa)

M 406ta H1 Hell) y 60.73talGHit 90.73 eH2 HoulH Al l 30 408teH1Hivl 60.73toltiital 30.73teH2Henintel 29 4eeleH1Het 90 73telt210nl to.73teH2Hal i LICEN898 CONT ACT FOR TMil LER H2l NiME YtLtPHONE NVM$tR Area COO 4 Ronald Byrd/Licentin; Engineer i 6 l0 i l 4 i 3 i? i ,2 il i 8l2 CoierttTE oNE uNE poR e AggNT AitVRE oleCRino N Twie RteoRT H3, CAust sYtttM ,,,,, ,y,,,, ,,,,,,,,, ss CoMeoNENT *^lW;AC. age,oa,TAggt MANg;Ac. ng,9oRTAgt-I I I I I I I I i 1 1 1 1 I I' I l l l l l l l 1 l 1 i l I SUPPLEMENTAL REPORT ExFICTt0 Het MONTH DAY YEAR Sv0 MIS $10N emo tuacreo spewssioN oares G Yts tar v ~} No l l l AseTRACT<t - , , = .o . - % ar ..u.rr . 4;e ,oei On May 16, 1990, an Operations Shift Supervisor determined that the actions taken by the previous shift for an inoperable reactor water level l

l

' transmitter were not adequate to comply with the requirements of Technical.

Specification 3.3.2 (Isolation Actuation Instrumentation). The level transmitter was inoperable for 10.3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />; however, the affected channel was actually in the tripped condition for only 6.6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> during that time.

The failure to maintain compliance with the LCO requirements was due to an error by licensed operators. The Technical Specifications placed different LCO time limits on the different functions of the affected instrumentation.

In evaluating options to take advantage of the extended LCO time limits for I the Reactor protection System trip function, the Operations Shift Supervisor i and Shift Superintendent did nct ensure that a detailed technical review was performed to verify that the method of maintaining compliance with the Ghutdown Cooling isolation. function was adequate. ,

Improper assumptions and verbal communications not being fully understood were contributing factors. Meetings were held with all shift SR0s to discuss:

specific duties relative to Technical Specification compliance, the expectations of personnel performing technical reviews, and concise communications.

LER90007/SCMPFLR - 3 1 Is01C Peron MS L b83I J

Attachment to AECM-90/0109

<; a g,% va u.a.. . .

UCENSEE EVENT REPORT (LER) TEXT CONTINUATION aa aovio ow n tim-o*

ex,' inn nue ,

pasIUTV IBAEEE til . 00catt soutSta tan ggagegnagen wi p.ee tal via "t!MP S?.C Grand Gulf Nuclear Station 0 l5 l0 l0l0]4 11 16 910 -

010]7 -

3b o I? 0' ok van n . s= m==anc som an wim .

~

A. Reportable Condition On May 16, 1990, licensed operators failed to maintain complianco with the requirements of Technical Specification Action 3.3.2.b for an inoperable isolation actuation instrument (EIIS system code: JM). This condition is reported pursuant to 10CFR50.73(a)(2)(1)(B).

B. Initial Conditions The' plant was operating at approximately 100 percent power at the time of occurrence with the affected isolation valves in the normally closed position.

C. Description of Occurrence On May 16, 1990, a Licensed Shift Supervisor determined that the actions taken by the previous operations shift for an inoperable level transmitter were not adequate to comply with the requirements of Technical Specification 3.3.2. The level transmitter was inoperable'for 10.3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />. The total time of noncompliance with Limiting Condition for Operation (LCO) was 3.7 hours8.101852e-5 days <br />0.00194 hours <br />1.157407e-5 weeks <br />2.6635e-6 months <br />. The following discussion sununarizes the soquence of evnnts leading to the error.

'On May 16,-'1990 at 1144, reactor level transmitter 1B21-N080B was declared inoperable after a special inspection revealed that although it was functional, it did not fully meet environmental qualification requirements. The heat shrink around one of.the transmitter openings.did not completely seal the opening as required.. 'A Limiting Condition for

-Operation (LCO) was entered pursuant to Technical Specifications 3.3.1 and 3.3.2.

Technical Specification 3.3.1 (RPS Instrumentation) states: "With the number of OPERABLE channels less than required by the minimum OPERABLE channels per Trip System requirement (2 per Trip System) for one trip system, place the inoperable channel and/or that trip system in the

-tripped condition within twelve hours."

g o41iM 0007/SCMPFLR - 4 e

Attachment to AECM-90/0109 ane

• • ' us nunsao co uuroav e nesion ) -

UCENSEE EVENT REPORT (LER) TEXT CONTINUATION apaoveo ove ao me-o*

_ . sense vmm FAGIUTV steigt tu D00 stet seussem tal tem seuessen see - Phet la v... **em!P .:'n.t;

, ,4 Grand; Gulf Nuclear Station o Is lo lo lo l4 l1 l6 9;0 0l 0l 7 0 g0 0l3 or 0 p.

terr a as= ans e as==s == amen =< mic e muw nn .

4

% Technical Specification 3.3.2 (Isolation Actuation Instrumentation) k states: "With the number of OPERABLE channels less than required by tho'

$. minimum OPERABLE channels por Trip System requirement (2 per Trip System)

[ , for one trip. system, place the inoperable channel and/or trip system in L the tripped condition within one hour."

The operator's first response was to conservatively place trip unit 1B21-N680B to trip. This provided a "B" channel trip to both the RPS and SDC isolation trip-functions. The Shift Superintendent.then decided to take advantage of the extended LCO thne limit for the inoperable RPS channel to minimize potential plant transients. After confirming that

[ the LCO requirements were met, operators began investigating options for

- clearing the RPS channel trip.

The Shift Superintendent consulted with operations section supervision on a proposal to remove the trip condition from trip unit B21-N600B, reset the RpS trip logic, and place in effect administrative controls to restrict resetting the SDC isolation logic. This proposal was concurred with by the staff assistant and management.

At 1350 on May 16, Trip unit B21-N680B was removed from the tripped condition and the RPS trip was reset. An information tag was placed on the SDC isolation reset switch prohibiting the reset of the SDC isolation signal. The Shift Superintendent thought that the isolation channel for valve E12-F037B would remain tripped by this-action.

T When the next operations shift. began, the oncoming Shift Supervisor

_ questioned the actions taken for the SDC isolation function. Upon reviewing the isolation logic schematics,,it was realized that the "B" channel isolation logic for valve E12-F037B was not tripped:and that the LCO requirements were not being met. At 1633, handswitch C71-M611B was placed to " TEST" which provided the B channel trip and roostablished Technical Specification compliance.

Level transmitter B21-N080B was resealed and returned to operable status at 2158 on May 16.

-goahMH00007/SCMPFLR - 5 m -i.---n-

_ _ ._ i_-im. -in.nii i .mwii

1 f . Attachment to AECM-90/0109

~ '

ans sena v.s. auc6 an as;usavony con-mo=

UCENSEE EVENT REPORT (LER) TEXT CONTINUATION amovio ow wo sino-oio4

..- axenus e ave passm nam m oocae,= vie.n . ,, ,. .

,,, ou l naa -

"t!?JP - 2.1?:

Grand Gulf Nuclear Station o ;g ;o g o ; o l4 f g6 9 ;0 _ 0;o; 7 ogo og4 op o' 4 inn a== . m= = . ass == mec s mumm ,

'O. Apparent Cause The Shift Supervisor had performed a preliminary review of logic schematics in developing alternatives for clearing the Rps channel trip, but had not performed a detailed comprehensive review to verify Technical Specification compliance for the particular method chosen. The Shift Superintendent made the decision on the method of Technical Specification compliance based on j his knowledge-of how the system functioned and concurrence from operations section supervision. The Shift Superintendent received this concurrence based on approval of the general method of compliance and not on a detailed technical review.- Through various communications with the staff and  ;

management, the Shift Superintendent thought that a technical review had been completed..

The failure to maintain compliance with the LCO requirements was due to an error by licensed operators. The Operations Sh.ift Supervisor and Shift Superintendent did not ensure that a detailed technical review was performed to verify the adequacy of the actions taken. Improper assumptions and verbal communications not being fully understood were contributing factors.

E. Supplemental corrective Action An Incident Review Board (IRB) was convened on May 17 to investigate the incident. In addition, a !!uman Performance Enhancement System (HPES) evaluation was conducted.

The Operations Superintendent counseled the individuals involved and met with all SROs to discuss the event and its causes. These meetings focused on the following matters: the specific responsibilities and duties of the Shift Supervisor and Shift Superintendent relative to Technical Specification compliance and technical verifications, the expectations of personnel performing technical reviews, and concise communications with non-shift resources such that information or requests are clearly understood.

F. Safety Assessment Valve E12-F037B is in the Residual lleat Removal (RHR) discharge line to the upper containment pools. The line is used for emergency inventory makeup to the upper containment pools. The E12-F037B valve is normally closed during plant operation and was maintained closed during this event. The valve does not have an automatic opening feature. Emergency inventory makeup to the upper containment pools is accomplished only by operator actions. Therefore, the event did not compromise plant safety.

goaWNt90007/SCMPFLR - 6

.