ML18101A334

LER 94-012-00:on 941013,required Daily Calibr of Power Range Instrumentation Not Performed within Surveillance Interval Due to Personnel Error.Personnel Involved in Event Counseled & Procedure SC.OP-DD-ZZ-0D40(Z) revised.W/941114 Ltr

ML18101A334
Person / Time
Site:	Salem
Issue date:	11/14/1994
From:	HAGAN J J, PASTVA M J Public Service Enterprise Group
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-94-012-02, LER-94-12-2, NUDOCS 9411210395
Download: ML18101A334 (7)

Text

_;... p,., }t' \:) . e Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station U. S. Nuclear Regulatory Cormnission Document Control Desk Washington, DC 20555 Attn.: Document Control Desk SALEM GENERATING STATION LICENSE NO. DPR-75 DOCKET NO. 50-311 UNIT NO. 2 LICENSEE EVENT REPORT NO. 94-012-00 November 14, 1994 This Licensee Event Report is being submitted pursuant to the requirements of Code of Federal Regulation 10CFR50. 73 (a) (2) (i) (B). Issuance of this report is required within thirty (30) days of event discovery.

Sincerely, MJPJ:vs C -Distribution LER File 9411210395 941114 PDR ADDCK 05000311 {p?) / S PDR l he power in y1JUT han.3-. 95-2189 REV 7-92 NRC FORM 366 (5-92) .S. NUCLl;AR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104

-. EXPIRES 5/31/95 LICENSEE EVENT REPORT (LER) (See reverse for required number of digits/characters for each block) ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY .COMMISSION, .WASHINGTON, De 20555*0001, AND TO THE PAPERWORK REDUCTION .PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503. FACILITY NAME (1) DOCKET NUMBER (2) PAGE (31 1 OF05 Salem Generating Station Unit 2 05000 311 TtTLE(4) La.LOrimer:ric

\,Heat tlal.anceJ .L;al.cul.at.ions Not Performed Within the Specified Surveillance Interval On Both Units -. EVENT DATE (5) LEA NUMBER (6 REPORT NUMBER '71 OTHER FACILITIES INVOLVED (8 SEQUENTIAL MONTH DAY YEAR NUMBER 10 13 94 94 012 REVISION NUMBER 00 MONTH ' 11 .VEAR 14 . 94 FACILITY NAME DOCKET NUMBER Salem Unit 1 05000?72 FACILITY NAME DOCKET NUMBER 05000 OPERATING 1 THIS REPORT IS SUBMITTED PURSUANT TO'THE REQUIREMENTS OF 10 CFR §: {Check one or more (11 MODE (9) 20.402(b) 20.405{c) 50.73{a)(2)(iv) 73.71 (b) POWER 100% 20.405(a)(1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71 (c) LEVEL (10) 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii)

OTHER -. 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) (Specify in Abstract n-+--.:....:....:...:...,:.....:._

__ ___; __ 4.......-1--__:_..:....:....:..:_:,.----__,.+_,...+--:....:_:...:.,:__:_::_.:_---t below and in Text, NRC

• 20.405(a)(1)(iv)

X 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B)

Form 366A) ,,,.,. 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)

LICENSEE CONTACT FOR THIS LEA (12\ NAME Michael J. Pastva -LER Coordinator TELEPHONE NUMBER (Include Area Code) 609 339-5165 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13\ CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TO NPRDS CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TONPRDS SUPPLEMENTAL REPORT EXPECTED (14\ EXPECTED MONTH DAY YEAR I YES X NO . . (If yes, complete EXPECTED SUBMISSION DATE) SUBMISSION DATE (15) _ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16) On 10/13/94, required daily calibration of power range instrumentation was not performed.

Investigation revealed that during 1994 qn 1/8,, 7/5, 7/8, and 9/12 (Unit 2), and 2/26, 3/5, and 9/2 (Unit 1), the calibration was performed beyond the allowable.extension Technical Specification (TS) 4.0.2. These events are attributed to personnel error due to failure to follow procedure.

contributors to the 10/13 event were focus upon ongoing activities and common mis-perception (applicable to all the events) that the surveillance could be completed within 'the confines of a calendar day. Licensed personnel from the 10/13 event were counseled concerning their actions and Management expectations.

Operations Night Order Book entries were made to explain* the surveillance requirement and a procedure revision to enhance/clarify the surveillance interval.

All Licensed personnel and select Technical Department personnel, will review these events to ensure their understanding of the surveillance,interval.

During the present re-qualification cycle, all licensed personnel will receive

• training specific to these events. By additional procedure enhancement will be made to provide more focus on TS requirements and address human factors tied to procedure performance and review. NRC FORM 366 (5*92) e REQUIRED OF DIGITS/CHARACTE.

FOR EACH BLOCK -BLOCK NUMBER OF NUMBER DIGITS/CHARACTERS TITLE ' 1 UP TO 46 FACILITY NAME 2 8 TOTAL 3 IN ADDITION TO 05000 DOCKET NUMBER 3 VARIES PAGE NUMBER 4 UP TO 76 TITLE 5 6 TOTAL 2 PER BLOCK EVENT DATE 7 TOTAL 6 2 FOR YEAR 3 FOR SEQUENTIAL NUMBER LER NUMBER _ 2 FOR REVISION NUMBER 7 6 TOTAL 2 PER BLOCK REPORT DATE UP TO 18 -FACILITY NAME 8 8 TOTAL -DOCKET NUMBER OTHER FACILITIES INVOLVED 3 IN ADDITION TO 05000 9 1 OPERATING MODE 10 3 POWER LEVEL 11 1 CHECK BOX THAT APPLIES REQUIREMENTS OF 10 CFR 12 UP TO 50 FOR NAME 14 FOR TELEPHONE LICENSEE CONT ACT CAUSE VARIES 2 FOR SYSTEM 13 4 FOR COMPONENT EACH COMPONENT FAILURE 4 FOR MANUFACTURER

' NPRDS VARIES 14 , CHECK BOX THAT APPLIES -SUPPLEMENTAL REPORT EXPECTED 15 6 TOTAL 2 PER BLOCK EXPECTED SUBMISSION DATE

,* LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station Unit 2 DOCKET NUMBER 5000311 PLANT AND SYSTEM IDENTIFICATION:.

Westinghouse

-Pressurized Water Reactor LER NUMBER* 94-012-00 PAGE 2 of 5 Energy Industry Identification System (EIIS) codes are identified in the text as {xx} IDENTIFICATION OF OCCURRENCES:

Calorimetric (Heat Balance) Calculations Not Performed Within The specif Surveillance Interval On Both Units ' . Event Dates: (Unit 2) 1/8/94, 7/5/94, 7/8/94, 9/12/94, and 10/13/94 (Unit 1) 2/26/94, 3/5/94, arid 9/2/94 Discovery Date: 10/13/94 Report Date:

• 11/14/94 This report was initiated by Incident Report No.94-304. DESCRIPTION OF OCCURRENCES:

At approximately 0951 on October 12, 1994, the requirements of Technical Specification (TS) Tabl.e 4. 3-1, Item 2, for daily calibration of power range instrumentation

{IG} when above 15% of RATED THERMAL POWER, were met through satisfactory completion of the caloriinetric (heat balance-)

calculation.

At 0530 hours0.00613 days <br />0.147 hours <br />8.763227e-4 weeks <br />2.01665e-4 months <br /> on October 13, 1994, with reactor power at 100%, a controlled reactor shutdown, at 5% per hour, was begun in preparation for refueling outage 2R8. At approximately 2200 hours0.0255 days <br />0.611 hours <br />0.00364 weeks <br />8.371e-4 months <br /> (same day), decrease to 15% power was achieved and, at 2244 hours0.026 days <br />0.623 hours <br />0.00371 weeks <br />8.53842e-4 months <br /> (same day), the Unit was placed in MODE 3 (HOT STANDBY).

On October 13, 1994, the surveillance requirements of TS Table 4.3-1, Item 2, (including the maximum allowable extension per TS 4.0.2) were not met, due to failure to perform the once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> calibration of power range instrumentation.

Event discovery occurred on October 14, 1994. Investigation revealed other instances on both Units during 1994, where the surveillance requirements of TS Table 4.3-1 were performed beyond the allowable extension per TS 4.0.2: Unit 2 -January 8 *(reactor power 98.8%), July 5 (reactor power 43.3%), July 8 (reactor power 72.7%), and September 12 (reactor power 93.8%) and Unit 1 -February 26 (reactor power 70.6%), March 5 (99.0%) and September 2 (reactor power , ' I I

.. LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating station Unit 2 ANALYSIS OF OCCURRENCES:

DOCKET NUMBER 5000311 LER NUMBER 94-012-00 PAGE 3 of 5 TSs specify that the nuclear instrumentation system (NIS) power range calibration be performed at least once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, whenever rated thermal power (RTP) is greater than 15%. Procedure S2.RE-ST.ZZ-0001(Q), "CALORIMETRIC"CALCULATION", is used to complete this calibration.

In addition, during Monday through Friday, the Technical Department assists the Operations Department in the performance of this procedure.

The "DAILY ROUTINES" checklist log of Operations Directive Procedure, SC.OP-DD.ZZ-OD40(Z), "SHIFT ROUTINES", Step 5.16, specifies the time frame for surveillance performance as oaoo-1200 hours. In addition, the procedure description for Step 5.16 states "The interval between calorimetrics shall not exceed 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />".

• On October 13, 1994, Unit 2 operated above 15% power for approximately six hours and 53 minutes beyond the maximum allowable extension for the required .NISpower range calibration.

As such, approximately 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> transpired*

between the prior NIS calibration and when RTP was 15%. Other instances occurred on both Units where the maximum allowable extension for the required NIS power range calibration was exceeded; Unit' 2*-two hours, 55 minutes; five hours,* 25 minutes; six hours, 19 minutes; and eight hours, 14 minutes; and Unit 1 -two hours, 42 minutes; 9 minutes; and three hours. APPARENT CAUSE OF OCCURRENCES:

These events are attributed to "Personnel Error", as classified in Appendix B of NUREG_-1022.

The event of October 13, 1994 resulted from failure of the Nuclear Control Operator (NCO) to follow procedure

[Step 5.16 of SC.OP-DD.ZZ-OD40(Z)]

combined with failure of the Nuclear Shift Supervisor (NSS) to adequately review the completed shift routines.

A contributor was focus upon activities related to the ongoing Unit power reduction and removal the Unit from_service for the upcoming refueling outage. Another contributor was a common mis-perception that the surveillance interval was once per calendar day and that the surveillance could be delayed within the confines of a calendar day, until establishing a stable plant condition which would allow performance of the surveillance.

Existence of this misperception is reinforced by discovery of the additional events where the surveillance was not completed with the required time period. Analysis of failed barriers indicates the personnel errors were the result of less than adequate knowledge and training.

Thi? was evidenced by the misunderstanding the once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> surveillance requirement.

1-.. I. I --LICENSEE EVENT REPORT (LER) TEXT CONTINUATION

• Salem Generating Station Unit 2 PREVIOUS OCCURRENCES:

DOCKET NUMBER 5000311 LER NUMBER 94-012-00 PAGE 4 of 5 Previous events involving the.failure to perform the required daily NIS calibration occurred on December 8, 15, 16, and 26, 1977. These were identified as an.infraction in a Notice of Violation in NRC Inspection Report 50-272/78-02, dated February 17, 1978. The cause of these occurrences was attributed to ongoing Unit load transients,

• which did not permit the required stable conditions to.allow*

completion of the surveillance.

Corrective action included an Operations Night Order Book {NOB) entry on 1/28/78, instructing the Senior Nuclear Shift Supervisor

{SNSS) of the necessity to perform the _surveillance.

This NOB entry directed the SNSS to stop a load change, if required, to permit completion of the surveillanc.e within th_e required till\e frame. SAFETY SIGNIFICANCE:

These events are reportable pursuant to 10CFR50.73{a)

(2) (i) (B), due to failure to comply with the Limiting Condition For Operation requirements of TS Table 4.3-1, as well as TS 3.0.2, due to failure to perform the surveillance requirements within the.maximum allowable extension.

The safety signif of October 13 event is minimal as the approximate six hours 53 minutes the Unit operated until the requirements of TS no longer applied (i.e. entry into.MODE

3) is bounded by the requirements of TS 3.0.3.. The safety significance of the other occurrences is minimal based upon satisfactory completion of the surveillance following each event. In addition, in accordance with procedure, reaqtor power is maintained less than 100% and verified by an on-line calorimetric computer readout. The inputs to the on-line calorimetric computer readout are the same as the manual surveillance calculation.

CORRECTIVE ACTION: All Licensed personnel involved in the October 13 event have been counseled concerning their *actions and Management expectations regarding procedure compliance.

An Operations NOB entry, explaining the surveillance requirement, was issued on.October 26, 1994. SC.OP-DD.ZZ-OD40{Z) has been revised to enhance arid clarify the definition of. the surveillance interval.

Additionally, a NOB entry was made on November 8, 199*4, describing the procedure change and requiring all Senior Shift Supervisors to review this change with their licensed personnel.

• .e LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating station Unit 2 CORRECTIVE ACTION: (cont'd) DOCKET NUMBER 5000311 LER NUMBER 94-012-00 PAGE 5 of 5 As a result of these events, a review of all Operations TS surveillance requirements with frequencies of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> or less was performed to ensure TS compliance.

This review identified four surveillances that, although presently adequate, will be procedurally enhanced as part of the SC.OP-DD.ZZ-OD40(Z) revision effort. To ensure a clear understanding of the surveillance requirement, it has been specified, verbatim, in S1(2).RE-ST.ZZ-OOOl(Q).

This procedure change has been discussed with select Technical Department personnel, who perform this requirement.

• Based on interviews with involved personnel, Operations Management will revise SC.OP-DD.ZZ-OD40(Z), by February 28, 1995, to separate TS surveillance requirements from other routine evolutions.

This change is intended.to provide more focus on TS requirements and-address human factors tied to performance and review of the procedure.

All Licensed personnel and select members of the Technical Department, will review these events to ensure their understanding of

• the surveillance interval.

During the present re-qualification cycle, all licensed personnel will receive training specific to these events and TS surveillance interval requirements.

Additionally, the Training Department will review the initial Program -to ensure proper focus on TS interval requirements.

The aforementioned training and review will encompass both Salem and Hope Creek programs.

MJPJ:pc SORC Mtg.94-087