05000254/LER-1996-023-01, :on 961124,CR Emergency Filtration Sys Failed to Maintain Required Airflow Due to Cognitive Personnel Error.Instrument Loop for Gauge Fi 1/2-5795-307 Calibr

:on 961124,CR Emergency Filtration Sys Failed to Maintain Required Airflow Due to Cognitive Personnel Error.Instrument Loop for Gauge Fi 1/2-5795-307 Calibr

ML20133A579
Person / Time
Site:	Quad Cities
Issue date:	12/23/1996
From:	Peterson C COMMONWEALTH EDISON CO.
To:
Shared Package
ML20133A570	List: 05000254/LER-1996-023, Provides Commitments Re LER 96-023.Predefined Model Work Request Which Initiates Perodic Maint Procedure Initiated 05000254/LER-1996-023-01, :on 961124,CR Emergency Filtration Sys Failed to Maintain Required Airflow Due to Cognitive Personnel Error.Instrument Loop for Gauge Fi 1/2-5795-307 Calibr
References
LER-96-023-01, LER-96-23-1, NUDOCS 9612310167
Download: ML20133A579 (5)

LER-1996-023, on 961124,CR Emergency Filtration Sys Failed to Maintain Required Airflow Due to Cognitive Personnel Error.Instrument Loop for Gauge Fi 1/2-5795-307 Calibr

Event date:
Report date:
2541996023R01 - NRC Website

text

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LICENSEE EVENT REPORT (LER)

Form Rev. 2.0 i

hcihty N;me (1)

Docket Number (2)

Page (3)

Qtiad Cities Unit One 0l5l0l0 0l2l5 4

1 l of l 0 l 5 Title (4) He control room emergency filtration system failed to maintain required airflow due to a cogmtive personnel error, wtich allowed a f ow instrument loop to be incorrectly calibrated.

l Event Date (5)

LER Number (6)

Reponbete (7)

CO.or Facihtees involved (8)

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Month Day Year Year Sequential Revision Month Day Year Facihty Docke: Number (s)

Number Number Namea l

' ~ ~

4 Quad Cities 0l5l0l0l0l2l6l5 Unit 2 l

1l1 2l4 9l6 9l6

,0l2l3 0l0 1l2 2l3 9l6 0l5l0l0l0l l

l

{

OPFJLATING THIS REPORT 15 SUBMTITED PURSUANT TO THE REQUIREMENTS OF 10CFR g

MODE (9)

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

20A02(b) 20A05(c) 50.73(a)G)(iv) 73.71(b)

POWER 20A05(a)(1)0) 50.36(c)(1) 50.73(a)G)(v) 73.71(c)

LEVEL

- 20A05(a)(1)61) 50.36(c)G) 50.73(a)G)(vii)

Other (Specify (10) 1 l0l 0

- 20A05(aXI)0")

T50.73(a>G)c) 50.73(a)G)(viii)(A) in Abstreet 20A05(a)(l)'.sv) 50.73(a)G)0i) 50.73(a)G)(viii)(B) below and in

- 20A05(a)(1)(v) 50.73(a)C)6ii) 50.73(a)G)(x)

Text)

LICENSEE CON TACT FOR THIS LER (12)

TAME TELEPHONE NUMBER t

AREA 0)DE Charl;s Peterson, Regulatory Affairs Manager, ext. 3602 e3 ol9 6l5l4l-l2l2l4l1 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED lh THIS REP)RT (13)

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CAUSE

BY5 TEM M M80NENT MANUFACIVRER REPORTABG

CAUSE

SYSTFM COMPONENT MANUFACTURER REPORTABM TO NPRDS

'IU NPRD5 I

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l SUP 'EMENTAL REPORT EKPEu t.u (14)

Expected Month Day Year Submission lYES (if yes, complete EXPECTED SUBMIS$10N DATE) 70 Dato (15)

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ABSTRACT (Lenis no 1400 spaces, s.e. eppronanntely fifteen smglo-speco typewnnen Ames) (16) 1 ABSTRACT:

On November 24,1996 at 1037 hours0.012 days <br />0.288 hours <br />0.00171 weeks <br />3.945785e-4 months <br /> the control room emergency filtration system (CREFS) was declared inoperable because CREFS airflow was below the required minimum. A 4 hour4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> ENS phone call was made on November 24, 1996, at 1312 hours0.0152 days <br />0.364 hours <br />0.00217 weeks <br />4.99216e-4 months <br />.

The event was caused by a cognitive personnel error, which allowed a flow instrument loop to be incorrectly calibrated. On November 25, testing demonstrated that the permanent plant instrument was indicating 2000 scfm while actual flow, as measured by pitot tube traverse, was 1607 scfm, which is less than the technical specification (TS) required airflow.

Follow-up action included adjusting CREFS airflow to meet the TS required airflow, and calibrating the permanent plant instrument loop.

CREFS was declared operable on November 25 at 1540 hours0.0178 days <br />0.428 hours <br />0.00255 weeks <br />5.8597e-4 months <br />.

The impact of this event was minimal, as it is very unlikely that, during a loss of coolant accident (1.0CA), the control room (CR) personnel would have received radiation exposure in excess of the 30 rem to the thyroid limit of General Design Criterion (GDC) 19.

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LER 254\\96\\023.WPF 9612310167 961223 i

PDR ADOCK 050002 4 S

4

i 3

LJCENSEE EVEPfr REPORT (LER) TEXT CONTINUATION Form Rev. 2.0 l

FACILTTY.NAME (1)

DOCKET NUMBER G)

LER NUMBER (6)

PAGE0)

.{

Year Sequential Revision I

Number Number l

0l0 2 lOFl 0 l 5 Quad Cities Unit One.

0l5 0l0l0l2j5l4 9]6 0l2l3 rzxT mansy ine ry wenisc=6on symem (rus) coa.s - 64.ntit ed in the text as [XX j j

!PLANTANDSYSTEMIDENTIFICATION:

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

i~ EVENT-IDENTIFICATION: The control room emergency filtration system failed to maintain required

, airflow.due to a cognitive personnel error, which allowed a flow instrument loop to. be l incorrectly calibrated.

A.-

COW ITIONS PRIOR T0 EVENT:

i j

i Unit: One Event Date: November 24, 1996 Event Time:

1037 l

l Reactor Mode:

1 Mode Name:

Power Operation Power Level:

100%

)

]-

Unit: Two Event Date: November 24, 1996 Event Time:

1037 Reactor Mode:

1 Mode Name: Power Operation Power Level: 99%

i This report was initiated by Licensee Event Report 254\\96-023.

)

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

j temperature at any temperature.

V B. DESCRIPTION OF EVENTS:

}

j Problem Identification Form (PIF) # 96-3271 was initiated to document a discrepancy i

between the control room emergency filtration system (CREFS) airflow as recorded by QCOS 5750-02, " Control Room [NA] Emergency-Filtration System Monthly Test," and Interim l

Procedure.(IP) 96-0182, " Main Control Room Envelope Air In-Leakage Test." Airflow through the CREFS was recorded by QCOS 5750-02 as 2000 standard cubic feet per minute (scfm) at 1510 hours0.0175 days <br />0.419 hours <br />0.0025 weeks <br />5.74555e-4 months <br /> on November 2,1996, using permanently installed gauge FI 1/2-5795-307. On the same date_ (precise time unknown), the airflow through the CREFS was. recorded by IP 96-0182 as 1666 scfm, using a calibrated portable air data multimeter with a pitot tube traverse.

(A pitot tube traverse using a calibrated test instrument is considered the prime standard for airflow measurement, as it takes an array of airflow readings across the duct). The instrument loop for FI 1/2-5795-307 was calibrated on November 14, 1996, but was not compared to actual flow as measured by a calibrated test instrument.

- QCOS 5750-02 verifies CREFS airflow of 2000 scfm 10% as specified by technical specification (TS) 4.8.D.3.c, and also verifies that air pressure in the control room (CR) is ~1/8" water gauge (w.g.) positive or greater with air flow of 2000 scfm or less. On November 18, 1996, it was recognized that QCOS 5750-02 is required to satisfy the t'- hnical specification (TS) requirement of 2000 i 10% scfm, and PIF #96-3271 was

,iated. Airflow testing was performed on the CREFS on November 24,and it was decermined that the permanently installed gauge FI 1/2-5795-307 was not displaying an accurate airflow reading and the CREFS airflow was not being maintained at 2000 scfm

• 10%

as required by TS 4.8.D.3.c.

As a result, the CREFS was declared inoperable at 1037 hours0.012 days <br />0.288 hours <br />0.00171 weeks <br />3.945785e-4 months <br />, November 24, 1996, and Quad Cities Nuclear Station (QCNS) (both units) entered a 7 day Limiting Conditions for Operation (LCO) as required by TS 3.8.D.1.

LER 2%961023.WPF l

s

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e LICENSEE EVENT REPCLT (LER) TEXT Coffr!NUATION Form Rev. 2.0 FACILTTY NAME~(1)

DOCKET NUMBER (2)

LER NUMBER (6)

PAGE (3) 4 Year Sequential Revision Number Number Quad Citks Unit ome ol5l0l0l0l2l5l4 9l6 ol2l3 olo 3 lOFl 0 l 5 TEXT Energy industry idenufication System (Ells) < edes are identified in the text as [XXj After corrective actions were taken to adjust CREFS airflow to 1975 scfm, the CREFS LC0 was exited at 1540 hours0.0178 days <br />0.428 hours <br />0.00255 weeks <br />5.8597e-4 months <br /> on dovember 25, 1996.

4 C.

APPARENT CAUSE OF EVENT:

The root cause of this event was cognitive personnel error. Cognitive personnel failed to specify airflow loop calibration requirements to include a verification of actual airflow as compared to the flow indicator.

D.

SAFETY ANALYSIS OF EVENT:

The health and safety of the public was not impacted by this event. Gaseous releases to the environment are controlled by the primary and secondary containments, the off-gas and

, standby. gas systems, and other systems. The CR heating, ventilation, and air conditioning (HVAC) system does not mitigate or contribute to gaseous releases to the environment.

The potential impact of the event on CR personnel is that, had a loss of coolant accident (LOCA) occurred, releasing radiation to the environment, the CREFS would have supplied a lesser amount of filtered air to the CR emergency zone (the CR emergency zone consists of the CR, cable spreading room, aux electric room, and the CREFS equipment room). During the first I hour and 50 minutes of a LOCA, the CREFS is assumed to not be operating (reference the updated final safety analysis report (UFSAR) section 15.6.5.5.3.3),

allowing unfiltered air into the CR emergency zone. A CREFS airflow of less than the 1800 scfm minimum would provide less turnover of air in the CR emergency zone, allowing the 4

unfiltered air that entered the CR emergency zone before CREFS startup to remain in the CR emergency zone longer.

The design basis of the CREFS is specified in UFSAR section 6.4.1, which stare. "the control room habitability systems are designed so that radiation exposure of control room p rsonnel does not exceed the limits of NUREG 0800, Standard Review Plan (SRP) 6.4, or of General Design Criterion (GDC) 19 of Appendix A to 10CFR50." These references require radiation protection under design basis accident (DBA) conditions such that dose rates are limited to less that 5 rem whole body, 30 rem exposure to the thyroid, with the thyroid dose being the limiting factor from an occupancy exposure consideration. Scientific NUS S:nsitivity Calculation No. 6200.001-M-04, Rev 0, dated 11/01/96, " Analysis of CR Dose as a Function of Infiltration using Revised Dose Analysis Methodology," demonstrated that the 30 day, 30 rem thyroid limit of CR personnel-is not exceeded with an unfiltered infiltration rate as high as 9260 scfm. With a total airflow of 25,650 scfm to the CR emergency zone, an unfiltered in leakage of 9260 scfm is extremely improbable.

The recirculation mode of the CREFS (entered automatically upon detection of toxic gas) was-not affected by this event.

In addition, the smoke purge mode of the CREFS was not affected by this event.

't LER 254 96\\023.WPF i

e UCENSEE EVENT REPORT G ER) TEXT CONTINUATION Form Rev. 2.0 FACllJTY N AME (1)

DOCKET NUMBER (2)

LER NUMBER (6)

PAGE (3)

Year

$equential Revision llumber Number i Qumi Citka Unit ome 0l5l0l0l0l2l5l4 9l6 0l2l3 0l0 4 lOFl 0 l 5 TEXT E g Industry idenufication System (EIIS) codes are identified in the text as (XXj J

i E.

CORRECTIVE ACTIONS

Corrective Actions ComDieted:

1.

IP 96-0188, " Control Room Emergency Filtration System Airflow Test," was initiated and i

performed and the CREFS airflow was adjusted to 1975 scfm.

2.

The instrument loop for gauge FI 1/2-5795-307 was calibrated to reflect actual airflow, and was verified by a pitot tube traverse.

3.

QCTS 0440-01, " Control Room HVAC Air Filtration Unit In-Place Leak Test of the HEPA Filters," was performed and verified the HEPA filter leak rate at an airflow of 2000 scfm 10%.

4.

QCTS 0440-02, " Control Room HVAC Air Filtration Unit In-Place Charcoal Adsorber Leak i

Rate Test," was performed and verified the charcoal filter leak rate at an airflow of i

2000 scfm 10%.

Corrective Actions to be Completed:

1.

Initiate a predefine model work request which initiates a periodic maintenance i

procedure to perform a loop calibration for the loop of gauge FI 1/2 5795-307 which includes calibrating the reading of the permanent gauge to actual airflow as determined by a pitot tube traverse. Actions to be completed by February 28, 1997.

(NTS # 2541809602301; Maintenance Department).

2.

Perform a review of all predefine calibrations that support technical specification requirements and utilize calibration procedures QIP 100-11, QIP 100-17, QIP 100-18, and QIP 100-19. This review will ensure that the calibrations are being properly performed. Actions to be completed by June 2, 1997.

l (NTS # 2541809602302, Maintenance Department).

3.

Revise the existing process for post-surveillance data review to ensure that technical specification requirements are being satisfied. Actions to be completed by 4

j March 3, 1997.

(NTS # 2541809602303; Work Control Department) j F.

PREVIOUS EVENTS:

'The following similar Licensee Event Reports (LERs) have occurred since 1994 regarding cognitive personnel error:

265\\95-002

" Wrong PT fuse drawer opened on Bus 24 due to inadequate work practices" 254\\96-006 "5 entries into TS LC0 3.0A for primary containment breeches to support scheduled LLRTs on M01-1001-36A/B and M01-1001-37A/B and also for seat leakage check of 1-1001-68A with the Rx>212 degrees and/or Rx critical" 4

LER 254\\96\\023.WPF

LICENSEE EVENT REPORT (LER) TEXT COKrINUATION Form R v. 2.0 FACILTIT,N AME (1).,

DOCKET NUMBER (2)

LER NUMBER (6)

PAGE (3)

Year Sequential Revision Number Number Quad Citie: Unit one 0l5 0l0l0l2l5l4 9l6 0l-2l3 0l0 5 lOFl 0 l 5 TEXT Energy ladustry Identification System (EIIS) codes are identif ad in the text as [XXj 254\\96-018 "U-1 Rx Mode Switch moved to S/U Hot Standby prior to required surveillances being completed due to the wrong assumptions being made" G.

COMP 0NENT FAILURE DATA:

None.

i l

i i

LER 254\\M023.WPF i