ML20046D597

LER 93-005-00:on 930720,missed Surveillance on Containment Isolation Valve Occurred Due to Personnel Error & Mgt Deficiency.Enhanced Procedures,Training & Counseling. W/930819 Ltr

ML20046D597
Person / Time
Site:	Braidwood
Issue date:	08/19/1993
From:	Kofron K, Lau P COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
BW-93-0233, BW-93-233, LER-93-005-034, LER-93-5-34, NUDOCS 9308250062
Download: ML20046D597 (7)

Text

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. Comm:nws:lth Edison Braidwood Nuclear Power Station Route #1, Box 84 Braceville, lilinois 60407 Telephone 815/458-2801 August 19, 1993 BW/93-0233 U.S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555

Dear Sir:

The enclosed Licensee Event Report from Braidwood Generating ,

Station is being transmitted to you with the requirement of 10CFR50.73 (a) (2) (i) (B), which requires a 30-day written report. -

This report is number 93-005-00, Docket No. 50-457.

, 1 K. L. Ko ton Station Manager Braidwood Power Station Encl: Licensee Event Report No. 50-457/93-005-00 cc: NRC Region III Administrator NRC Resident Inspector INPO Record Center CECO Distribution List 9

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9308250062 930819 PDR ADOCK 05000457 !w 8 / 1 S PDR id V '

N3C FORM 366 U.S. CIJCLEAR CILOJLATEDtY Cup 04]SSION AFP30tfLD BY OMB CJ0. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH II LICENSEE EVENT REPORT (LER) $4,3"'O$^mgNIsfEcADIG 3 c BURDEN ESil ATE O THE INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, (See reverse for required ruber of digits / characters for each block) WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY WAME (1) DOCKET NtMBER (2) PAGE (3)

Braidwood 2 05000457 1 OF 6 TilLE (4) ciissed surveillance on containment isolation valve due to personnet error and management deficiency FVINT DATF (5) ifR NUMRER (6) REPORT DATE (7) OTHER F ACIllTIES INV0tVED (8)

E AL R FACILITY NAME DOCKET NUMBER MONTH DAY YEAR YEAR MONTH DAY YEAR None 05000 FAC NAM C ET B 07 20 93 93 -- 005 -- 00 08 19 93 9 0

(&fRATING y THIS RFPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CIR i: (Check one or more) (11)

MCDE (9) 20.402(b) 20.405(c) 50.73(a)(2)(iv) 73.71(b) payr" " *" "

LEVEL (10) 100 20.405(a)(1)(li) 50.36(c)(2) 50.73(a)(2M vii) OTHER

[ 20.405(aM1)(lii) X 50.73(a)(2)(i) 50.73(a)(2)(viii)( A) (Specify in a w 20.405(aM1)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) 20.405(a)(1)(v) 50. 73(a)(2)(i i i ) 50.73(a)(2)(x) NRC Form 366A) llCENSEE CONT ACT FOR THlS (f R (12)

AAME TELEPHONE NUMBER (include Area Code)

P. Lau, Regulatory Assurance (815)458-2801 x2957 i

CCMPlf TF ONE t INE FOR E ACM COMPOWINT F AllORE DESCRIBED IN THIS RFPORT (13) ,

CAUSE SYSTEM COMPOWENT 0 B MANUFACTURER CAUSE SYSTEM COMPONENT MANUFACTURER g No s

1 SUPPt f ME NTAL REPORT [KPECTfD (14) EXPECTED O TH DAY YEAR YES SUBMISSION (If yes, complete EXPECTED SUBMISS!ON DATE).

• DATE (15)

ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single spaced typewritten lines) (16)

On June 11, 1993, Operations Department performed the RC Drain Tank l Containment Isolation Valve Stroke Test satisfactorily. On July 1, the Inservice Testing Coordinator (ISTC), after reviewing test results,

initiated a Surveillance Request (GSRV) to increase the test frequency for valve 2RE9159B (RE). The ISTC incorrectly had Nuclear Group entered as the responsible department. On July 20, the RE system surveillance was late.

i The Nuclear Group leader contacted Primary Group, responsible for the RE system. The Primary Group Leader informed Operationc of the missed surveillance which was then completed the same day. The causes of the event were: work group misassignment, the GSRV item not reviewed by the Station Surveillance Coordinator, Nuclear Group leader assumed the GSRV item appeared on Primary Group's list, and no proceduralized routing process or formal _ training for station surveillance requests. The l corrective actions include procedural enhancements, training, and counseling. There have been previous reportable missed surveillances, however, the previous causes and corrective actions are not applicable to this event.

MC FORA 366 (5-92) idRC FORM 366A U.S. WUCLEAR RE0UULTORY C0MMISSION APPROVED BY OMB No. 3150-0104 (5-92) . EXPIRES 5/31/95  ;

ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEMENT BRANCH TEXT CONTINUATION (MNES 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (1) DOCKET WlmBER (?) LER WLMBER (6? PAGE (3)

Braidwood 2 YEAR SEQUENTIAL REVISION m en w wer e 2 OF 6 05000457 93

-- 005 -- 00 TEXT (If more space is reevired. use edditional copies of NDC Form 366A) (17)

A. PLANT CONDITIONS PRIOR TO EVENT:

Unit: Braidwood 2; Event Date: July 20, 1993; Event Time: 0950; Mode: 1 - Power Operation; Rx Power: 100%;

RCS [AB] Temperature / Pressure: NOT/NOP <

B. DESCRIPTION OF EVENT:

There were no components or systems unavailable that contributed to this event.

On June 11, 1993, Braidwood Operations Department personnel performed surveillance BWVS 6.3.3-9, Reactor Coolant Drain Tank Containment Isolation 3 Valve Stroke Test. The surveillance met required acceptance criteria. The i completed surveillance was routed, and was reviewed on June 11, 1993, by the Operating Shift Supervisor, and by the Assistant Technical Staff Supervisor on June 18, 1993. On July 1, 1993, the surveillance was reviewed for trending by the Inservice Testing (IST) Coordinator. During the review, the IST Coordinator determined that the stroke time for valve 2RE9159B showed an increasing trend and was required to be placed on increased test frequency. The IST Coordinator initiated a General Surveillance Program (GSRV) Request form to have the valve entered in GSRV t for increased test frequency. The IST Coordinator then carried the form to the GSRV data entry clerk for entry into the GSRV computer program. A discussion ensued concerning four fields of the form that were not completed. These fields were: Responsible Department, Required By, Plant Condition, and Priority. Based upon the recommendations of the IST Coordinator, the GSRV data entry clerk entered the following information in l the fields: Department - TN (Systems Engineering Nuclear Group); Required '

By - BWVP 200-2; Plant Condition - 1,2,3,4; Priority - 1. The form was  !

not reviewed by the responsible Department Head or the Station Surveillance Coordinator, contrary to BwAP 1400-2, Surveillance Request Form Completion.

i This.is partially due to the fact that the Station Surveillance Coordinator had been assigned other duties for an extended period of time. Upon completion of the form, the GSRV data entry clerk entered the information into the GSRV computer program with a date due of July 12, 1993, and a  !

Critical Date of July 19, 1993.

On the afternoon of Tuesday, July 6, 1993, the GSRV data entry clerk 1 printed out the weekly surveillance schedules and routed them to the i appropriate departments. Upon receipt of the schedules for the Systems Engineering groups, the System Engineering clerk placed the schedules for i each group in their respective routing boxes. Upon receipt of the schedule for the Nuclear Group, the group leader reviewed the weekly schedule, and

N3C FORD 366 (5-92)

CRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 (5 92) EXPIRES 5/31/95 ESTIMATED BURDEN PER kESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS RECARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFcaMATION AND RECORDS MANAGEMENT BRANCH TEXT CONTINUATION (MhBB 7714), U.S. NUCLEAR REGULATORY COMMIS$10N, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150 0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON. DC 20503.

TACitITY NAME (1) DOCKFT NtMBER (2) LER NtMBER (6) PAGF (3)

Braidwood 2 YEAR SEQUENTIAL REVISION 05000457 93 0 3 OF 6

- 005 -

TEXT (If more space is reovired. use additional copies of NRC Form 3664) (17) noticed that there was a surveillance on his sheet for the RE (Reactor Equipment Drains) System. He determined that since this surveillance concerned the RE system, it did not belong to the Nuclear Group, and assumed that it was also on the responsible department's schedule.

On the afternoon of July 12, 1993, the GSRV data entry clerk printed out the weekly surveillance schedules and routed them to the appropriate departments. On the morning of July 13, 1993, upon receipt of the schedule for the Nuclear Group, the group leader reviewed the weekly schedule, and determined that the RE system surveillance was still on the schedule. The group leader assumed that the GSRV computer program had not been updated to reflect that the surveillance had been completed.

On July 19, 1993, the Nuclear Group surveillance schedule for July 12, 1993 was returned to the GSRV data entry clerk with the surveillance for valve 2RE9159B lined out with no explanation. The GSRV data entry clerk took no action concerning the line out. On the afternoon of July 19, 1993, the GSRV data entry clerk printed out the weekly surveillance schedules and routed them to the appropriate departments. On the morning of July 20, 1993, upon receipt of the schedule for the Nuclear Group, the group leader reviewed the weekly schedule, and determined that the RE system surveillance was still on the schedule and was in fact past the critical date. The Nuclear Group leader then contacted the Primary Group leader '

concerning the missed surveillance. The Primary Group Leader informed the Assistant Technical Staff Supervisor and the Operating Engineer of the ,

missed surveillance. The missed surveillance was completed by the Operations Department on July 20, 1993.

Emergency Notification System (ENS) notification was not required per 10CFR50.'72.

C. CAUSE OF THE EVENT:

The primary cause of the event was cognitive personnel error. The In- 6 Service Testing Coordinator made a misassignment of the responsible work group to perform the surveillance when it was placed on an increased test l frequency. The Systems Engineering Nuclear Group was assigned responsibility instead of the correct department, which was the Operating Department. Additionally, the new surveillance form generated for the increased frequency surveillance was not reviewed and approved by the ,

Department Head and the Station GSRV Coordinator in accordance with BwAP ,

1400-2 prior to being entered into the GSRV computer program. The required signature are to indicate approval of the data supplied and acceptance of  ;

the work.

Sf3C FORh 366 (5-02)

NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 (5-92) -

EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS RECARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEMENT BRANCH TEXT CONTINUATION (MkBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACitITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

Braidwood 2 YEAR SEQUENTIAL REvlslON 05000457 93 4 of 6

-- 005 -- 0 TEXT (if more space i reavired use additional copies of NEC rorm 366A) (17)

One contributing cause of the event was also cognitive personnel error.

When the GSRV listing of surveillances was distributed and an unfamiliar surveillance appeared on the Nuclear Group's listing, the group leader improperly assumed that it also appeared on another group's list. When the next week's listing was received by the Nuclear Group, a questioning attitude was not exercised. When the third printout was received by the s Nuclear Group on July 20, 1993, the Primary Group Leader was finally contacted in regards to the surveillance in question.

A second contributing cause to this event was a management deficiency in the surveillance program. There is no proceduralized routing process for station surveillances after they are completed. After the valve was tested on June 11, 1993, it was not identified as being required to be placed on increased testing frequency until July 1, 1993. This resulted in a less than timely routing for the surveillance from the Operating Shift Supervisor, through Systems Engineering, and ultimately arriving at the IST Coordinator.

Another contributing cause of this event was a management deficiency, with a lack of formal training for department surveillance coordinators and clerical personnel involved with the surveillance program. Several individuals involved with this event were new in their positions, and had not received any formal training on the processing of surveillances (Nuclear Group Leader and IST Coordinator).

D. SAFETY ANALYSIS:

Though 2RE9159B (RCDT to Gas Analyzer Outside Isolation Valve) was not stroked in accordance with the increased frequency requirements, this event had no effect on plant or public safety. This event was of no significance for the followir.g reasons:

1) The plant was stable at 100% power and no abnormal additions were  ;

made to the RCDT during 7/19/93 and 7/20/93.

2) 2RE9159B was closed at the time the surveillance was due on 7/19/93 ,

until it was stroked for the required surveillance on 7/20/93. The valve was returned to the closed position upon completion of the required surveillance.

i

3) 2RE9159B receives an auto close signal on a Phase A Containment Isolation Signal to ensure Containment is isolated from the Auxiliary Building and the environment. Since this valve was i

already in the closed position, no valve movement would have been required should a Phase A have occurred.

W3C 70#C 366 (5-92)

'kRC FORM 366A U.S. NUCLEAR REGULATORY CCM ISSION APPROVED BY OMB No. 3150-0104 (5-92) EXP!RES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS lhFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDING BURDEN ESilMATE TO LICENSEE EVENT REPORT (LER) T ,< E INFoRMAiloN AND RECORDS MANAGEMENT BRANCH TEXT CONTINUATION (Mas m4), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACit1TY NAME (T) DOCKET NtMBER (2) LER NtMRER (6) PA T (3)

Braidwood 2 yggp SEQUENTIAL REVISION 05000457 93 5 OF 6

-- 005 -- 0 l

t TEXT (if more space is reovired. use additional copies of NRC Form 366A) (17)

All Engineered Safeguards Features and the Reactor Protection System were operable during the time frame that 2RE9159B was inoperable due to the failure to perform the increased stroke surveillance.

E. CORRECTIVE ACTIONS:

Immediately upon identification, the missed surveillance was completed by the Operations Department on July 20, 1993.  ;

A training program will be developed to train present and future Departmental Surveillance Coordinator (s) and Surveillance Scope Operator (s) l on the surveillance program procedures, in order for them to better understand the GSRV process and their functional responsibilities. This will be tracked to completion by action item 457-180-93-00501.

The importance of self checking and attention to detail were reemphasized with the Nuclear Group Leader and ISTC involved with this event. The fostering of a questioning attitude through the STAR process (Stop, Think, Act, Review) was the main focus of this discussion. This event was also the topic of a site wide In-House Operating Experience Report. This Report was made a part of required tailgate training for all site personnel.

The BwAP 1400 series procedures and tb.e Surveillance Coordinator position-cescriptions will be revised to rcilect the current site processes and functions. Improvements will be considered to increase the GSRV Program efficiency and effectiveness. A proceduralized routing process for ,

completed surveillances will also be considered. This will be tracked to i completion by action item 457-180-93-00502.

F. PREVIOUS OCCURRENCES: ,

LER 50-456/91-009, Gas Decay Tank Sample Not Obtained Due to Procedure Deficiency LER 50-456/93-003, Missed Technical Specification Surveillance Due to Wiring Discrepancies LER 50-457/91-004, Personnel Error Results In Late Performance Of Technical Specification Surveillance t LER 50-457/91-005, Sample Required By Technical Specifications Obtained Late Due to Personnel Error ,

i LER 50-457-93-004, Core Reactivity Normalization Surveillance For Unit 2 Cycle 4 Not Performed In Required Time Frame 1

7 b

NRC FORM 366 (5-92)

ORC FORM 366A U.S. NUCLEAR RECULATORY COMMISSION APPR"VED BY OMB No. 3150-0104 (5 92) . EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQ' JEST: 50.0 HRS.

FORWARD COMMENTS REGARDlhG BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEMENT BRANCH TEXT CONTINUATION (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASH!hGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MAN AGEMENT AND BUDGET, WASHlWGTON, DC 20503.

FACILITY NAMF (1) DOCKE T NLMBER (2) ifR NLMBER (6) PAGE (3)

Braidwood 2 yEAg SEQUENTIAL REVISION NUpprp Nuwpre 6 Op 6 05000457 93 -- 005 -- 00 TEXT (!f more space is reovired, use additional copies of NRC Form 366A) (17)

There have been previous occurrences of failure to perform technical specification surveillances within the specified time periods. Corrective actions were implemented addressing both root and contributing causes. Previous corrective actions are not applicable to this event.

G. COMPONENT FAILURE DATA:

P None

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