ML20045A146

LER 93-009-00:on 930504,discovered That Surveillance Test Procedure for Control Bldg Chilled Water Sys Quarterly Pump Missed Due to Cognitive Personnel Error.Administrative Procedure Will Be revised.W/930604 Ltr

ML20045A146
Person / Time
Site:	River Bend
Issue date:	06/04/1993
From:	Booker J, Lorfing D GULF STATES UTILITIES CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-93-009, LER-93-9, RBG-38590, NUDOCS 9306090437
Download: ML20045A146 (8)

Text

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GULF STATES UTILITIES COMPANY 41vt A ElND STATON POST (WFtCE BGX 220 ST F RANCISVILLE. LOU'5)AN A 7077h A6f A CODE Eb4 C:!b 0094 346 fsf.51 k

June 4, 1993 RBG- 38500 File Nos. G9.5, G9.25.1.3 ,

1 U.S. Nuclear Pegulatory Conunission Document Control Desk Washington, D.C. 20555 i

Gentlemen:  !

River Bend Station - Unit 1 '

Docket No. 50-458 Please find enclosed Licensee Event Report No.93-009 for River Bend Station -Unit 1. This repon is submitted pursuant to 10CFR50.73. i Sincerely, i t

J&csnu .-pr J. E. Booker Manager - Safety Assessment and Quality Verification River Bend Nuclear Group '

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. cc: U.S. Nuclear Regulatory Commission 611 Ryan Plaza Drive, Suite 400 ,

Arlington, TX 76011 i i

NRC Resident Inspector ,

P.O. Box 1051 St. Francisville, LA 70775 INPO Records Center 700 Galleria Parkway l' Atlanta, GA 30339-5957

\1r. C.R. Oberg Dublic Utility Commission of Texas 7800 Shoal Creek Blvd., Suite 400 North Austin, TX 78757 Department of Environmental Quality Radiation Protection Division P.O. Box 82135 Baton Rouge, LA 70884-2135 ATTN: Administmtor e

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} A t ii j f f N A PJ E (1, DOCh.E l NLMBE R I?) OAGE p i!1YLH DEND STATION 05000 158 , of 5 jW W QUAHTERLY IN-SLHVlCL INSPECTION SlJHVEILLANCE FOR CONTHOL HUILDING LCHII. LED WATER PD!D 'D' WAS >!1SSED DUE TO A COGNITIVE H131AN FHROH i LVENT DATE (5) ~~lf L ER NUMDER (6- le DEPORT NUMBER (7) 01HER F ACILITIES INVOLVED (8) l . ,

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At 1800 on May 4,1943, with the reactor in Operational Condition 4 (Cold Shutdown) for planned outage (PO) 43-01, Operations personnel discovered that surveillance test procedure (STPF410-6312. " CONTROL BLDG CHILLED WATER SYSTEM QUARTERLY PUMP j AND VALVE OPERABILITY DIV H" had not been completed for the control building chilled l water pump. HVK"PID, within the required Technical Specification time frame, rendering HVK-P1D inoperable on 4/18/93. The redundant pump HVK*PlB, was already inoperable due to failure of the applicable portion of (STP)-410-6312 on 2/10/93. Therefore, the Division H control building ventilation system (HVK/HVC) was rendered inoperable. Therefore, this report is submitted pursuant to 10CFR50.73(a)(2)(i)(B) as operation prohibited by the Technical Specifications and 10CFR50.73(a)(2)(vii)as an event in which a single cause or condition caused an independent train to become inoperable.

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The root cause of this event was a cognitive error in that comments were not properly l

transferred from the STP data package cover sheet to the " green shect." Corrective actions include procedural improvement, briefings for Operations personnel, and revision of

[ Administratis e Procedure ( ADM F0015, " Station Surs eillance Test Prognun" to require including ,

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{ a copy of the STP data package cover sheet with each " green sheet" with an estimated l p completion date of Julv 31, 1993. pl

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REQUIRED NUMBER OF DIGITS / CHARACTERS FOR EACH BLOCK DLOCK NUMBER OF NUMBER DIGITS / CHARACTERS 1 UP TO 46 FACIUTY NAME DOCKET NUMBER 3 IN ADDITIO TO 05000 3 VAR;ES PAGE NUMBER 4 UP TO 76 TITLE 5 EVENT DATE 2 PER BLOCK 7 TOTAL E LER NUMBER 3 FOR SEQUENTIAL NUMBER 2 FOR REVISION NUMBER 7 R PORT DATE 2P B OCK UP TO 18 -- FACiUTY NAME 8 TOT AL - DOCKET NUMBER CM F ANE NOMD 3 IN ADD l TION TO 05000 9 1 OPERATlNG MODE 10 3 POWER LEVEL

FiEOUtPEVENTS OF 10 CFR CHECK BOX THAT AFPUES g UP TO 50 FOR NAVE 14 FOR TELEPHONE CAUSE VAR;ES 2 FOR SYSTEM 13 4 FOR COVPONENT EACH COMPCNENT FA! LURE 4 FOR MANUFACTURER NPROS VAR'ES

'4 SUPP1 EMENT AL REPORT EXPECTED CHECK BOX THAT APPUES 15 EXPECTED SUBMl$510N DATE 2 PER BL CK

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OF RIVER BEND STATION 05000 458 _

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.At 1800 on May 4,1993, with the reactor in Operational Condition 4 (Cold Shutdown) for planned outage (PO)-93-01, Operations personnel discovered that surveillance test procedure (STP)-410-6312, " CONTROL BLDG CHILLED WATER SYSTEM Q'UARTERLY PUMP AND VA.LVE OPERABILITY DIV II" had not been completed for the control building ,

chilled water pur.p (*P*), HVK"PlD within the required Technical Specification time frame, rendering HVK*PlD inoperable on 4/18/93. The redundant pump (*P*) HVK*PIB, was already inoperable (reference TR LCO 93-023) due to failure of the applicable portion of (STP)-410-6312 on 2/10/93. Therefore, the Division II control building ventilation system (HVK/HVC) (*VI*) was rendered inoperable. To document the non-compliance with the  :

surveillance requirement, this repon is submitted pursuant to 10CFR50.73(a)(2)(i)(B) and -

10CFR50.73(a)(2)(vii) as an event in which a single cause or condition caused an independent train to become inoperable. .

INVESTIGATION The surveillance was determined to be overdue based on the Technical Specification surveillance interval requirement and verification of the date and time of the previous perfonnance. This STP is the quarterly in-service inspection (ISI) test for the Division II control building chilled water pumps (HVK*PIB/PID) and their associated valves. This STP t is required by Technical Specification Surveillance Requirement 4.0.5 which states that >

inservice testing of ASME Code Class 1, 2, and 3 pumps and valves shall be perfonned in accordance with Section XI of the ASME Boiler and Pressure Vessel Code at the surveillance intervals specified in Section XI. In this case, the surveillance interval is at least once every 92 days.

Following discovery, Operations personnel reviewed the Technical Specification requirements ,

under Section 3.7.2, entered the action statement requiring that the Division I control building filter train be opemted in the emergency mode (limiting condition for operation i (LCO)93-170), and initiated a condition report (CR NO. 93-0252) to investigate this event.

The STP was successsfully performed in its entirety by 5/14/93 at 0800.

On 10/30/92 a full perfonnance of STP-410-6312 was successfully completed for both HVK*PIB & PID. A panial perfonnance limited to the HVK"PID ponion was satisfactorily completed on 12/23/92 to verify pump reference values. The next full  !

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SEQ 4NTm EEv$QN NUMBER NUMBER 000 HIVER BEND STATION 458 33 009 -

00 3 5 w m.,c.=,,,,.w.u..m n . m = - m on perfonnance date of the STP was scheduled for completion by 2/22/93. On 2/10/93, the STP was signed in and the portion of the test for HVK*PIB failed. The Shift l Supervisor / Control Opemting Foreman (SS/COF) elected to secure the STP as a partial unsatisfactory perfonnance for HVK*PlB only, declared HVK*PIB inoperable and initiated a tracking limiting condition for operation, TR LCO 93-023, on HVK*PIB. Comments were entered on the data package cover sheet of STP-410-6312 indicating a partial perfonnance and failure of HVK*PIB only. This left HVK*PID untested pending resolution of issues concerning the test methodology.

The SS/COF then filled out the surveillance test scheduling completion / exception fonn l

, (" green sheet") to document the panial perfannance and test exception request for HVK*PIB. The comment contained in the STP data package cover sheet which indicated that only the HVK"PlB ponion had been perfonned and that the test exception being requested was only for HVK*PlB was not transferred to the " green sheet". The " green sheet" is routed to the STP scheduling group for scheduling subsequent STPs and tracking test exceptions. Upon receipt of this " green sheet," the STP scheduling group listed a test i exception for the entire STP (no " comments" to indicate that the exception was for PIB only) against TR LCO 93-023, effectively removing the entire STP from the schedule tracking system with the HVK*PID portion unperfonned. The surveillance for HVK*PID expired with the 25 percent tolerance on 4/17/93 based on the satisfactory perfonnance of 12/23/93; .

however, this condition went undetected due to the erroneous test exception of 2/10/93. A subsequent unrelated review of STP " comments" detected the missed surveillance on 5/4/93.

ROOT CAUSE Based on a task analysis of this event and personnel interviews, the root cause for missing the scheduled perfonnance due date on HVK*PID was a cognitive error that occurred when comments were not properly transferred from the STP data package cover sheet to the " green ,

sheet. " The February 27,1993 surveillance test of main steam line isolation valve (MSIV)

IB21*AOVFO22B was dispositioned as " acceptable with comments" when in fact the valve was stuck. Following this event (ref. LER 93-006), GSU reviewed all current STP perfonnances, for a total of 1200. Out of these STPs, this event (LER 93-009) was the only incorrectly identified test exception discovered as a result of this review. Therefore, GSU i concludes that this is an isolated case of cognitive human error, and is not indicative of a programmatic problem.

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MANAGEMENT AND BUDGET.WASM:NGTON, DC 20503. I F ACILITY NAME (t) DOCK.ET NUMBER (2) LIR NUMBf R qs) PAGE(4 bEGUENiaAL 8'EV'hCN i YEAR NUMBER NJMBER 05000 OF RIVER BEND STATION 458 93 009 00 4 5 wam - av.c..,.w. w .. - - . a c w m n The event described in LER 93-006, differs signiGcantly from the subject event (LER 93- ,

009). The incorrect disposition of the surveillance on the MSIV resulted from an improper evaluation of the condition of the valve. In the current event, LER 93-009, the test exception was properly indicated on the STP cover sheet but the comments were not I transferred to the " green sheet."

Ll A review of previous LERs revealed a similar event, LER 89-034. In this case, the " green sheet" was not properly 611ed out to indicate a panial perfonnance of the ten-hour run for  :

the standby gas treatment system 'A' train under STP-257-0201. When the data was entered into the surveillance test scheduling tracking system (STSTS), the " green sheet" was misinterpreted and the surveillance was updated as a full perfonnance of STP-257-0201. The error was not detected on input, nor during independent verification following input. This resulted in missing the required ten-hour run of the SGTS 'B' train.  ;

CORRECTIVE ACTION Administrative Procedure (ADM)-0015, " STATION SURVEILLANCE TEST PROGRAM" has been revised to include a requirement that a copy of the data package cover sheets for all ISI STPs will be transmitted to the STP scheduling group along with the green sheet. This revision also includes clariGcation of requirements and instructions for Hlling out the green ,

sheet emphasizing " partial perfonnances" and " test exception" comment requirements.

In 1989, Operations issued a departmental memo to SS/COFs to provide additional detail and conventions to be used in 611ing out ISI STP green sheets. The content of this memo has t been re-emphasized to the SS/COFs. This memo will be revised to add additional guidance by July 1,1993.

Administrative procedure (ADM)-0015 will be revised to require including a copy of the STP l data package cover sheet with each " green sheet." The estimated completion date for this I revision is July 31, 1993.

All Operations senior reactor operators (SROs) will be briefed on this event and its corrective actions via required reading, estimated to be completed by 8/31/93.

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00 93 5 5 Tux e,w w.;. v.w.a . .~. cw.w unc u .ve <m Additional enhancements to the program which are under evaluation include the following:

Inclusion of lessons learned from this event in position-specific continuing training for all plant staff personnel responsible for surveillance testing.

Development of an ISI component ID matrix by Opemtions and the STP scheduling ,

group.

1 SAFETY ASSESSMENT  :

The purpose of STP-410-6312 is to insure the operability of pumps, HVK*PIB and l HVK*PID by perfonning in-service testing of these components to the ASME Section XI {

Standard within the frequency required by this code. Although HVK*PID was inoperable from 4/17/93 until 5/4/93, without the required actions of Technical Specification 3.7.2 being entered, the satisfactory performance of this same STP on 5/14/93 verified that HVK"PlD was functional during this period of time and was capable of perfonning its intended safety function per design. .

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o NRC FOAV 366A (5-92)