05000254/LER-1996-020-01, :on 960907,CR Emergency Filtration Sys Declared Inoperable.Caused by Operator Knowledge Weakness.Operators Declared CR Emergency Filtration Sys Inoperable & Entered 14-day LCO

:on 960907,CR Emergency Filtration Sys Declared Inoperable.Caused by Operator Knowledge Weakness.Operators Declared CR Emergency Filtration Sys Inoperable & Entered 14-day LCO

ML20128M792
Person / Time
Site:	Quad Cities
Issue date:	10/07/1996
From:	Peterson C COMMONWEALTH EDISON CO.
To:
Shared Package
ML20128M754	List: 05000254/LER-1996-020, Forwards LER 96-020-00.Commitments Included in LER & Submitted 05000254/LER-1996-020-01, :on 960907,CR Emergency Filtration Sys Declared Inoperable.Caused by Operator Knowledge Weakness.Operators Declared CR Emergency Filtration Sys Inoperable & Entered 14-day LCO
References
LER-96-020-01, LER-96-20-1, NUDOCS 9610160182
Download: ML20128M792 (4)

LER-1996-020, on 960907,CR Emergency Filtration Sys Declared Inoperable.Caused by Operator Knowledge Weakness.Operators Declared CR Emergency Filtration Sys Inoperable & Entered 14-day LCO

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(iv), System Actuation 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability 10 CFR 50.73(a)(2)(i) 10 CFR 50.73(a)(2)(viii)(A) 10 CFR 50.73(a)(2)(ii) 10 CFR 50.73(a)(2)(viii)(B) 10 CFR 50.73(a)(2)(iii) 10 CFR 50.73(a)(2)(x)
2541996020R01 - NRC Website

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LICENSEE EVENT REPORT (LER)

Form Rsv. 2.0 Ficuity Name (2) doc.et Number (2)

Page (3)

Quad Cities Unit one 0l5l0l0l0l2l5l4 1 l of l 0 l 4 Title (4) i Control Roorn Emergency Filtration System inoperable due to operator knowledge weakness.

Event Date (5)

LER Number (6)

Report Date (7)

Other Facihties involvmi (8)

Month Day Year Year Sequential Revision Month Day Year Facility Docket Numberts)

Number Number Names Ol5l0l0l0l2l6l5 0l9 0l7 9l6 9l6 0l2l0 0l0 1l0 0

7 9

6 0l5l0l0l0]

l l

4 OPERATING THIS REPORT IS SUBMFITED PU LSUANT TO TIE REQU REh' ENTS OF 10CFR MODE (9)

(Check one or more of the following) (11) 4 1

20.402(b) 20.405(c) 50.73(a)(2)(iv) 73.71(b) j POWER 20.405(a)(1)(i) 50.36(c)(1)

T50.73(a)(2)(v) 73.7i(c)

LEVEL 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii)

Other (Specify (10) 0 l2l 3

20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) in Abstract i

20.405(a)(1)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) below and in 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)

Text) d LICENSEE CON TACT FOR THIS LER (12)

NAME TELEPHONE NUMBER AREA CODE Charlas Peterson, Regulatory Affairs Manager, ext. 3602 3

0l9 6l5l4l-l2l2l4l1 j

COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE

SYSTEM COMPON ENT MANUFACTU RER R

LE

CAUSE

SYSTEM COMPONENT MANUFACTURER LE a

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I SUPPLEMENTAL REPORT EXPECTED (14)

Expected Monih Day Yeas Submmion lYES (If yes. complete EXPECTED SUBMISSION DATE)

'"Y"]NO Date (15) l l

l AB5 TRACT (lanut la 1400 spacca, i.e., approumately fiticen umgle-space typewnnen haca) (16)

ABSTRACT:

On 9/7/96 at 0530 hours0.00613 days <br />0.147 hours <br />8.763227e-4 weeks <br />2.01665e-4 months <br />, Unit One was in Power Operation Mode at 23% power and Unit Two l

was in Power Operation Mode at 85% power. The Control Room ventilation system was in the i

isolated recirculation mode with the Toxic Gas Analyzer (TGA) de-energized. The operators were unable to start the Air Filtration Unit (AFU) booster fans during the performance of l

the monthly surveillance. When the operators were unable to determine the cause they declared the Control Room Emergency Filtration System inoperable, entered a 14 day 1

Limiting Condition for Operation (LCO), and made an Emergency Notification System (ENS) call at 0556 hours0.00644 days <br />0.154 hours <br />9.193122e-4 weeks <br />2.11558e-4 months <br />.

l The root cause of this event was operator knowledge weakness.

When the AFU booster fans failed to start, the operators failed to recognize the relationship between the AFU l

booster fans and the toxic gas analyzer.

Corrective actions include incorporating this event in the operator required reading, including this LER in Modifications and Lessons j

Learned training, and changing the surveillance procedure.

The safety significance of this event is minimal because in the event of a Loss of Coolant Accident (LOCA), the ventilation system would have remained in recirculation for a sufficient time to identify and correct the problem.

4 LER254\\M020.WPF 9610160182 961007 PDR ADOCK 05000254 g

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i-LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Fonn Rev. 2.0 j

FACIprY NAbtE (1)

DOurt NUMBER (2)

LER NUMBER (6)

PAGE (3)

Year Sequential Revision

' Nuniber Nuadier Quad Cities Unit One 0l5 0l0l0l2l5l4 9l6 0l2l0 0l0 2 lOFl 0 l 4

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TEXT Energy Ir.d.;ry law.Gcation System (EIIS) codes are ik.6;md in the text as [XX]

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PLANT AND SYSTEM IDENTIFICATION

General Electric - Boiling Water Reactor - 2511 MWt rated core thermal power.

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j EVENT IDENTIFICATION: Control Room Emergency Filtration Systems inoperable due to operator knowledge weakness.

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A.

CONDITIONS PRIOR TO EVENT

i Event Date: September 7, 1996 Event Time: 0530 Unit: One j

Reactor Mode:

1 Mode Name:

Power Operation Power Level:

23 i

Unit: Two Reactor Mode:

1 Mode Name:. Power Operation Power Level:

85 1

j This report was initiated by Licensee Event Report LER254\\96-020.

Power Operation (1) - Mode switch in the RUN position with average reactor coolant-temperature at any temperature.

B.

DESCRIPTION OF EVENT

On 9/6/96 Q0S 5750-04, " Control Room Ventilation Toxic Gas Analyzer Inoperable Outage f

Report" was initiated to perform preventive maintenance on the Control Room Toxic Gas Analyzer [45]. Step 7 of QOS 5750-04 states in part, "If desired,-due to analyzer being in the tripped condition, place the toxic gas analyzer in the untripped condition by lifting wire...".

This step' allows the Air Filtration Unit (AFU) [VI]

to be run with the Toxic Gas Analyzer deenergized.

The Operations entered "NA" for this step as the operators did not need to operate the AFU. At 0400 hours0.00463 days <br />0.111 hours <br />6.613757e-4 weeks <br />1.522e-4 months <br /> the Toxic i

Gas Analyzer was de-energized to perform the prevantive maintenance.

On o 7/96 at approximately 0500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> operators were preparing to perform QCOS 5750-02, " Control Room Emergency Filtration System Monthly Test". Step H.2 of this

[

procedure states to verify the toxic gas analyzer system is in service or initiate l

the QOS 5750-04 Outage Report. The Unit Supervisor verified that QOS 5750-04 had already been initiated but did not review the existing outage report as this was not -

considered necessary to complete step H.2.

Outage Reports do not normally contain conditional steps required for a surveillance procedure.

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At 0530 hours0.00613 days <br />0.147 hours <br />8.763227e-4 weeks <br />2.01665e-4 months <br /> the operator attempted to perform step H.8 of QCOS 5750-02 to start the AFU. At this time the "A"

and "B" Booster fans could not be started. The Toxic Gas 4

Analyzer was still deenergized under Outage Report QOS 5750-04 which prevented the I

Booster fans from starting.

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k IIR254\\96\\020,WPF

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LICENSEE EVENT REPORT (LER) *1XT COfGINUATION Form Rry. 2.0 F.ACIIJTY NAME (1)

DOCKET NUMBER (2)

LER NUMBER (0)

PAGE (3)

Year Sequential Revision Number Number Qual Cities Unit Chie 0l5l0l0lol2l5l4 9l6 ol2l0 ol0 3 lOFl o j 4 TEXT Energy industry identification System (EIIS) codes are identif,ed in the text as (XX]

The Operators could not determine the reason why the booster fans would not start and declared the AFU inoperable and entered the 14 day Limiting Condition for Operation (LCO) in accordance with Technical Specification 3.8.H.1.a.

A 4 hour4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> Emergency Notification System (ENS) phone call was made at 0556 hours0.00644 days <br />0.154 hours <br />9.193122e-4 weeks <br />2.11558e-4 months <br />.

I C.

APPARENT CAUSE OF EVENT:

The root cause of this event was operator knowledge weakness.

When the AFU booster fans failed to start, the operators failed to recognize the relationship between the AFU booster fans and the toxic gas analyzer.

The contributing cause of this event is inadequate procedures. The procedural direction necessary to operate the AFU with an inoperable toxic gas analyzer was contained in QOS 5750-04, step 7.

However, QCOS 5750-02 did not contain a specific reference to tha applicable step of Q0S 5750-04 nor did it provide any specific information as to the intent of the outage report. As a result, the operators did not identify the need to lift the appropriate lead to bypass the AFU interlock.

D.

SAFETY ANALYSIS OF EVENT:

The safety significance of this event is considered minimal. The AFU is a manually initiated system and the steps to initiate the AFU with the toxic gas analyzer inoperable were included in QOS 5750-04. In a non-accident condition, or in a Loss Of Offsite Power (LOOP), the inability to start the AFU booster fans is insignificant, as no radioactive particles or vapors requiring filtration would be present. In the condition of a concurrent LOCA and LOOP, the toxic gas analyzer would be bypassed allowing the booster fa~ns to start. Therefore, the only condition of concern for the inability to start the AFU booster fans is a LOCA condition.

In accordance with Updated Final Safety Analysis Report (UFSAR) Table 15.6-7,Section III, the Control Room intake will immediately isolate on a loss of Coolant Accident (LOCA).

This will act to minimize the intake of outside air and potential contamination into the Control Room. The AFU start (manual start) is assumed to be 110 minutes following the LOCA.

It is reasonable to assume in the event of a LOCA continuous troubleshooting would have commenced and that the system would have been able to be started within the 110 minutes.

LER254\\M020.WPF

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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rev. 2.0 EACILTTY NAME (1)

DCrKET NUMBER (2)

LER NUMBER (6)

PAGE (3) i 1

Year Sequential Revision Nuahr Number Quad Cities Unit one 0l5 0l0l0l2l5l4 9l6 0l2l0 0l0 4 lOFl 0 l 4 TEXT Energy Industry identification System (Ells) codes are identif,ed in the text as [XX]

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E.

CORRECTIVE ACTIONS

Corrective Actions ComDleted 4

1 l-1.

The Operators declared the Control Room Emergency Filtration System inoperable and entered the.14-day LCO.

2.

This event has been incorporated in' operator required reading.

1 Corrective Actions to be Completed 1.

A description of this event will be presented to Licensed Operations personnel in retraining by 01/31/97. (Training - NTS#2541809602001) i 2.

QC05 5750-02, " Control Room Emergency Filtration System Monthly Test" will be j

revised by 10/27/96. (Operations - NTS#2541809602002) i

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i F.

PREVIOUS OCCURRENCES

- A search conducted for LER's over the last two years, which involved operator

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knowledge weakness, identified the following previous events:

254\\96-006 Technical Specification 3.0.A was incorrectly invoked, due to procedural and operator knowledge deficiencies on technical specification requirements, when primary to secondary containment j

flowpaths were established during Local Leak Rate testing.

254;96-017 Manual scram taken during reactor startup when reactor water level increased following unplanned opening of all main turbine bypass valves due to an inadequate procedure.

G.

CONPONENT FAILURE DATA:

Not applicable.

LER254\\96W20.WPF