05000295/LER-1997-010-01, :on 970404,radiation Area Surveys Were Missed. Caused by Inadequate TS Review.Nso,Unit Supervisor & Shift Engineer,Counseled

:on 970404,radiation Area Surveys Were Missed. Caused by Inadequate TS Review.Nso,Unit Supervisor & Shift Engineer,Counseled

ML20138J608
Person / Time
Site:	Zion File:ZionSolutions icon.png
Issue date:	05/05/1997
From:	Brennan N COMMONWEALTH EDISON CO.
To:
Shared Package
ML20138J595	List: 05000295/LER-1997-010-01, :on 970404,radiation Area Surveys Were Missed. Caused by Inadequate TS Review.Nso,Unit Supervisor & Shift Engineer,Counseled
References
LER-97-010-01, LER-97-10-1, NUDOCS 9705080273
Download: ML20138J608 (4)

LER-1997-010, on 970404,radiation Area Surveys Were Missed. Caused by Inadequate TS Review.Nso,Unit Supervisor & Shift Engineer,Counseled

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) 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)
2951997010R01 - NRC Website

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LICENSEE EVENT REPORT (LER)

FACILITY NAME DOCKET NUMBER PAGE 0l5l0l0l0l2l9l5 1 l0Fl 0 l 4 ZION NUCLEAR POWER STATION UNIT TITLE Missed Radiation area surveys because of inadequate Technical Specification review; no impact EVENT DATE LER NUMBER REPORT DATE OTHER FACILITIES INVOLVED MONTH DAY YEAR YEAR SEO.

REV.

MONTH DAY YEAR FACILITY NAMES DOCKET NUMBER (S) 710N UNIT 2 0 l 6 l 0 l 0 l 0 l 3 l 0 l4 nla ola 9 l7 917 olilo olo ols ois 917 I I I I I I I THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR 5: (CHECK ONE OR MORE OF THE FOLLOWING) 5 20.402(b) 20.405(e) 50.73(a)(2)(iv) 73.71(b)

POWER 20.405(a)(1)(1) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c) 0l0l0 LEVEL 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(v11)

OTHER (Specify in 20.405(a)(1)(iii) x 50.73(a)(2)(i) 50.73(a)(2)(viii)(A)

Abstract below 20.405(a)(1)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) 36 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)

LICEN5EE CONTACT FOR THIS LER NAME TEtEPHONF NUMBfR N.M. BRENNAN REG. ASSURANCE X2380 81817 71alel-12inlel4 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT

^

CAUSE

SYSTEM COMPONENT MANUFACTURER

CAUSE

SYSTEM COMPONENT MANUFACTURER TO NPRDS TO NPRDS I

I I I I I I I

I II I i I I

I I I I I I I

I I I I I I SUPPLEMENTAL REPORT EXPECTED EXPECTED MONTH DAY YEAR SUBMISSION YES. (If ves. comolete EXPECTED SUBMISSION DATE)

M NO DATE l

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ABSTRACT (Limit to 1400 spaces, i.e.

approximately fifteen single space typewritten lines).

At 0350 hours0.00405 days <br />0.0972 hours <br />5.787037e-4 weeks <br />1.33175e-4 months <br /> on April 4,1997. Area radiation monitor ORE-0006 " Primary Sample Room Area Monitor" failed. The Unit Supervisor (US) reviewed the Technical Specifications (TS). Zton Operational Determination Manual (20DM) Process Radiation (PR) section. and Zion Radiation Protection (ZRP) ZRP 5820-12 "Out of Service Surveillance for Radiation Monitors." On April 6, 1997 the same US who was on j

shift on Apr11 4, reviewed the TS and this time noticed TS 3.14-1 table reference to OR0006. The consequences of the event are two missed area surveys to meet the TS requirements for a failed radiation detector. The causes of this event are I)a cognitive error by the US in his review of the TS; 2)no confirming review required or performed by either the Shift Engineer (SE) or Nuclear Station Operator (NS0): 3)less than adequate questioning attitude by any subsequent reviewers. A contributing factor in this event was an error in the ZRP 5820 12. Corrective Actions: 1)US, SE and NSO have been counseled. 2)ZRP 5820-12 has been corrected. 3)The US has presented this event at a Licensed Sh1ft Supervisor meeting to ensure awareness and emphasize lessons learned. 4)The US w111 modify procedures to require a confirming review be performed by the NSO. 5)0perating Training Department will determine the type of training required as a result of this LER and the resultant procedure changes and incorporate lessons learned into the liCPnsed Operator Training. (NUREG code A) 9705080273 970505 PDR ADOCK 05000295 S

PDR ZLER\\97010.ler(1)

l LICENSEE EVENT REPORT (LER) TEXT CONTINUATION t

FACILITY NAME DOCKET NUMtlER LER NUMBER PAGE l

YEAR SEO.

REV.

t ZloN NUCLEAR POWER STATION

[

0l5l0l0l0l2l9l5 9l7 0l1l0 0l0 0l2 0l4

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0F i

TEXT-Energy Industry Identification System (EIIS) codes are identified in the text as [XX]

i A.

PLANT CONDITIONS PRIOR TO EVENT i

i Unit 1 MODE 5-CSD Rx Power 0 RCS [AB] Temperature / Pressure 89f/ atmos Unit 2 MODE 5-CSD Rx Power 0 RCS [AB] Temperature / Pressure 82f/37psig l

B.

DESCRIPTION OF EVENT

- i At 0350 hours0.00405 days <br />0.0972 hours <br />5.787037e-4 weeks <br />1.33175e-4 months <br /> on April 4.1997, Area radiation monitor ORE-0006 [IL]" Primary Sample Room Area Monitor" i

failed. Monitor ORE-0006 is a common area radiation monitor listed in Technical Specifications (TS)

{

table 3.14-1 as OR-0006 [IL] and is controlled from Unit 1 Radiation Monitor Display System (RMDS)

[

[IL] control panel. Unit 1 Unit Supervisor (US) contracted Radiation Protection (RP) to determine the problem with the monitor. RP reported that local area covered by ORE-0006 (primary sample room) was

<1mr/hr and could not repair the monitor immediately. The US had the Unit 1 Nuclear Station Operator (NS0) remove the monitor from scan on the Unit 1 RMDS panel.

l The NSO questioned the US if there were any surveillance to be conducted, but did not review any i

procedures himself. The ORE-0006 monitor is on RMDS panel 2 which contains only TS Radiation l

monitors.

At approximately 0430 hours0.00498 days <br />0.119 hours <br />7.109788e-4 weeks <br />1.63615e-4 months <br /> the US completed his review of Technical Specifications (TS), but he failed l

to adequately review Table 3.14-1. He then reviewed the wrong section of the Zion Operational l

Determination Manual (20DM). ie: Process Radiation (PR) section instead of the Area Radiation (AR) j section. Next he reviewed ZRP 5820-12 "Out of Service Surveillance for Radiation Monitors," step 3 l

" Monitors not requiring Routine Surveillance." ZRP 5820-12 step 3 incorrectly listed ORE-0006 as not requiring a routine surveillance. The Unit Supervisor (US) called the RP department, and they also l

referred to ZRP 5820-12 step 3 and confirmed his incorrect findings. The US filled out a PT-14E j

" Degraded Equipment Status" (DEL), a log used to track the inoperable non-TS equipment. There is no i

clear understanding of why the US looked at PR instead of AR in the ZODM.

I At 0530 hours0.00613 days <br />0.147 hours <br />8.763227e-4 weeks <br />2.01665e-4 months <br /> on April 4,1997, the Primary NSO. US. Shift Engineer (SE), and the RP Supervisor were

- l notified to sign the DEL paperwork. The SE questioned whether provisional monitoring was required, l

and the US stated. "None that I could find. RP confirms this." The SE stated that the radiation monitor was an old Westinghouse monitor (which are usually TS related), but he failed to follow-up.

)

1 l

Although this DEL was documented in everyone's turnover, no other licensed individual challenged the DEL. Periodic Test (PT) PT-0 Appendix N Unit 1 " Unit 1 Radiation Monitor Check Sheet for all Modes of

- Operation" was performed daily with DEL recorded for the inoperable ORE-0006.

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i ZLER\\97010.ler(2)

l LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITY NAME DOCKET NUMBER LER NUMBER PAGE YEAR SEO.

REV.

ZION NUCLEAR POWER STATION 0l5l0l0l0l2l9l5 9l7 0l1l0 0l0 0l3 0l4

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0F TEXT Energy Industry Identification System (EIIS) codes are identified in the text as [XX)

B.

DESCRIPTION OF EVENT (Continued)

On April 6, 1997, at 0450 hours0.00521 days <br />0.125 hours <br />7.440476e-4 weeks <br />1.71225e-4 months <br /> area radiation monitor ORT-ARIO [lL]" Auxiliary Building Area Monitor Elevation 542" went into instrument fail. The same US who was on shift on April 4.1997, reviewed the TS and this time noticed TS 3.14-1 table reference to OR0006. He then again ru earched the 200M.

This time he referenced the index and realized OR0006 is in the ZODM section AR under ORE-0006.

Realizing and confirming his error. he informed the Shift Engineer and RP. Initially the RP Supervisor again indicated that OR0006 is a non TS monitor with no surveillance, but later at 0505 hours0.00584 days <br />0.14 hours <br />8.349868e-4 weeks <br />1.921525e-4 months <br /> found documentation (an " attachment" to the ZRP 5820-12) that confirmed daily area surveys is required. A technician was dispatched to perform the survey immediately.

At 0552 hours0.00639 days <br />0.153 hours <br />9.126984e-4 weeks <br />2.10036e-4 months <br /> on April 6.1997. RP reported that the area survey was complete and satisfactory. The consequences of the event are two missed area surveys to meet the TS requirements for a failed Primary Sample Room radiation detector.

C.

CAUSE OF EVENT

The causes of this event are 1) a cognitive error by the Unit Supervisor (US) in his review of the Technical Specifications: 2)no confirming review required or performed by either the Shift Engineer (SE) or Nuclear Station Operator (NS0): 3)less than adequate questioning attitude by any subsequent reviewers of the NSO/US/SE turnover sheets. PT 0 Appendix N. or Degraded Equipment Log. A contributing factor in this event was an error in the RP procedure.

D.

SAFETY ANALYSIS

The in-operability of ORE-0006 " Primary Sample Room Area Monitor" did not create any unmeasured release of radioactive materials to the environment. Technical Specifications requires the Sample l

Room to have a surveillance conducted every 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> during the time that the monitor is out of service. The purpose of the primary sample room area radiation monitor (OR-0006) is to provide early warning of a high radiation level which may require evacuation of personnel from the affected area l

during normal and accident conditions.

l The impact on personnel safety for not performing the actions required as a result of the radiation monitor's inoperability was insignificant. All personnel working in the area monitored by OR-0006 are required to wear digital alarming personnel dosimetry which have a dose rate and dose accumulation alarm capability. In addition, personnel are required to utilize portable survey meters (ion chambers) whenever obtaining or handling primary coolant samples within the primary sample room. In the event of an unexpected increase in dose rates. both devices would immediately alert the individual (s) to the changing conditions During this time, however.1RIA-PR49 " Vent Stack "SPING" Monitor" was out of service (see PT-14 #

97000233 and W/R # 970035759) and the Radiation Protection (RP) department were taking " grab samples" every shift (8 hour9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />). as directed by ZRP 5820-12 "Out of Service Surveillance for Radiation Monitors."

As a result of this sampling process no un-monitored releases were made. The pathway to the environment from the Sample Room for Noble gas is through the ventilation system to the Vent Stack.

l ZLER\\97010.ler(3)

1 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION l

FACILITY NAME DOCKET NUMBER LER NUMBER PAGE YEAR SEO.

REV.

ZION NUCLEAR POWER STATION 0lSl0l0l0l2l9l5 9l7 0l1l0 0l0 0l4 0l4

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0F TEXT Energy Industry Identification System (E!IS) codes are identified in the text as [XX]

E.

CORRECTIVE ACTIONS

1.

Nuclear Station Operator. Unit Supervisor and Shift Engineer have been counseled, 2.

ZRP 5820-12 "Out of Service Surveillance for Radiation Monitors" step 3 " Monitors not requiring Routine Surveillance" has been corrected.

3.

The Unit Supervisor has presented this event at a Licensed Shift Supervisor meeting to ensure awareness and emphasize lessons learned.

4.

The Unit Supervisor will modify the following procedures to require a confirming review be performed.

l PT-14 " Inoperable Equipment Surveillance Tests."

PT-14E " Degraded Equipment Status."

5.

Operating Training Department will determine the type of training required as a result of this LER and the resultant procedure changes and incorporate lessons learned into the Licensed Operator Training.

i F.

PREVIOUS EVENTS SEARCH AND ANALYSIS l

l A review of Zion's Nuclear Tracking System database has revealed a previous occurrence in which Licensed Shift Supervisors performed an inadequate review, refer to LER 95-006.96-007 and 96-009.

Zion Station has identified that problems exist in the area of TS surveillance complia' and are taking steps to eliminate this problem.

G.

COMPONENT FA1LUPE DATA None l

1 ZLER\\97010.ler(4) i