ML17329A515: Difference between revisions
StriderTol (talk | contribs) (Created page by program invented by StriderTol) |
StriderTol (talk | contribs) (Created page by program invented by StriderTol) |
||
| (2 intermediate revisions by the same user not shown) | |||
| Line 16: | Line 16: | ||
=Text= | =Text= | ||
{{#Wiki_filter:1!ndiana Michigan Power Company Cook Nuc!ear P!ant".ne Cook Place Bridgman.Ml~9106 616 465 5901 May 20, 1992 | {{#Wiki_filter:1 | ||
92-004-00 Sincerely, A.A.Blind Plant Manager/sb Attachment c D.H.Williams, Jr.tA.B..Davis., Region~?Q'. | !ndiana Michigan Power Company Cook Nuc!ear P!ant | ||
DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31$0C)10el.OFFICE OF | ".ne Cook Place Bridgman. Ml ~9106 616 465 5901 diag INDIANJL NlCHlG4N POWER May 20, 1992 United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-58 Docket No. 50-315 Document Control Manager: | ||
DC 20503.DOCKET NUMBER (2)PA E 3 0 5 0 0 0 3 1 5 1 OF 0 4 TITLE Icl | ln accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ort S stem the following report is being submitted: | ||
92-004-00 Sincerely, A. A. Blind Plant Manager | |||
TO NPAOS | /sb Attachment c D. H. Williams, Jr. | ||
The test is accomplished by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.The missed surveillance was identified on 4-24-92.The surveillance procedure was immediately performed. | tA. B.. Davis., Region~? | ||
All test acceptance criteria were met.The missed surveillance occurred as a result of personnel error during the review process.The findings of this event were reviewed with the involved personnel by their supervisors. | E. Fitzpatrick Q'. | ||
P. A. Barrett B. F. Henderson R. F. Kroeger B. Walters Ft. Wayne NRC Resident Inspector J. F. Stang NRC J. G. Keppler M. R. Padgett G. Charnoff, Escr. | |||
D. Hahn XNPO S. J. Brewer/B. P. Lauzau B. A. Svensson gAN g 61SR Q'c Oyga | |||
NRC FORM 366 V S. NUCLEAR REGULATORY COMMISSION (649) APPROVED 0MB NO. 3150410C EXPIRES: C/30I92 ESTIMATED BURDEN PER RESPONSE TO COLIPLY WTH THIS INFORMATION COLLECTION REOUEST. 500 HRS. FORWARD LICENSEE EVENT REPORT (LER) COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMFNT BRANCH (F630), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON. DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31$ 0C)10el. OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON. DC 20503. | |||
FACILITY NAME lll DOCKET NUMBER (2) PA E 3 D. C. Cook Nuclear Plant Unit 1 0 5 0 0 0 3 1 5 1 OF 0 4 TITLE Icl Missed Surveillance on Boric Acid Flow Path due to Personnel Error During Procedure Review Process EVENT OATK (5) LER NUMBER LSI REPORT DATE (7) OTHER FACILITIES INVOLVED (4) | |||
SEOVENTIAL REVOKE FACILITYNAMES DOCKET NUMBFR(SI MONTH OAY YEAR YEAR NVMSEII NVMSEII MON)'H OAY YEAR 0 5 0 0 0 04209292 0 0 4 0 0 0 5 THIS REPORT IS SUBMITTED PURSUANT T0 THE R SOU(A EMENTS OF 10 2 0 9 2 C FR (): IC>rrCC Onr Or mrrr Of tnr fOIIOwinpl (11 0 5 0 0 0 OPERATING MODE (4) 20A02(SI 20AOS(cl 50.73(el(2IGrl 73.71(SI POWER 20A05(e) ()Ill) 50M(el)1) 60.73(el(2) (r I 73.7((c) | |||
LEYEL, cR ~ 'ro"'C 8 9 9 20A054)(1l(EI 20AOS(e) (I ) (IIII 50.34(c)(2) 50.73(e)(2) lll 50.7 3 4l(2Hrii) 60.73(e)12) (rill)I Al OTHER ISorc>fy >n Aottrrct Oelow rnrf In Fret, HAC Form SSSA> | |||
V 20A05 4) (1 ) tlrl 60 7 34) l2) (9) 50.73 4 I (2 I 4lil ) I 5 I | |||
)O; r . carr.@ 20.4054)(1 I (rl 50.73 Iel(2)(lli) 50,7S( ~ ) IS)(el LICENSEE CONTACT FOR THIS LER (12) | |||
NAME TELEPHONE NUMBER AREA CODE J. R. Sampson, Operations Department COMPLETE ON! LINE FOR EACH COIAPONENT FAILURE DESCRIBED IH THIS REPORT IIS) 616465-5901 CAUSE SYSTEM COMPONENT MANUFAC. | |||
TUAER FPOATABLF. | |||
TO NPAOS | |||
~~Xo .. r;rl CAUSE SYSTEM COMPONENT MANUFAC. | |||
TUREA EPOATABL TO NPAOS k~m c | |||
@o~5 SUPPLEMENTAL REPORT EXPECTED IICI MONTH DAY YEAR EXPECTED SUBMISSION DATE (15) | |||
YES llfyrt, compirtr EXPECPEI> SVSMISSION DATEI NO ABSTRACT l(,lmit to tc00 torcrL I r., rpproelmrtrly lilrrrn tinplr tprtr tyPrwnttrn linwl l14) | |||
On 4-20-92, contrary to Technical Specification (TS) 4.1.2.2.a.l, the seven-day test to prove the operability of the boration flow paths from the refueling water storage tank and the boric acid storage tank was not performed as scheduled. The test is accomplished by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel. The missed surveillance was identified on 4-24-92. The surveillance procedure was immediately performed. All test acceptance criteria were met. The missed surveillance occurred as a result of personnel error during the review process. | |||
The findings of this event were reviewed with the involved personnel by their supervisors. | |||
NRC Form 344 (649) | NRC Form 344 (649) | ||
NRC FORM 3rrSA (689)U.S.NUCLEAR REGULATORY COMMISSION | |||
DC 20503.FACILITY NAME (1)DOCKET NUMBKR (2)LER NUMBER (Sl | NRC FORM 3rrSA (689) | ||
NUMSSR | LICENSEE EVE TEXT CONTINUATION U.S. NUCLEAR REGULATORY COMMISSION REPORT (LERI t APPROVED OMB NOr 31504104 EXPIRES: rU30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 500 HRS. FORWARD COMMENTS RFGARDING BURDEN ESTIMATE TO THE RECORDS ANO REPORTS MANAGEMENT BRANCH (P430). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, ANO TO 1NE PAPERWORK REDUCTION PROJECT (3)500104), OFFICE OF MANAGEMENTANO BUDGET, WASHINGTON. DC 20503. | ||
TS 4.1.2.2.a.l requires at least once per seven days that the boration flow paths from the refueling water storage tank (RWST)(EIIS/CB-TK) and the boric acid storage tank (BAST)(EIIS/CB-TK) be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.The missed surveillance procedure was discovered by an Operations Department Engineer on 4-24-92, The surveillance test was last performed on 4-13-92.The TS action statement was entered at 1255 hours and the 1-OHP 4030.STP.002V surveillance procedure was started, completed, and reviewed by 1314 hours on 4-24-92.A review of the completed surveillance noted that the surveillance acceptance criteria were satisfied and the action statement was exited at this time.On 4-20-92, the involved Unit Supervisor (Senior Reactor Operator)reviewed the 1-OHP 4030.STP.002V paperwork completed during his shift.Following this review, the Unit Supervisor recorded the completed sections of the 1-OHP 4030.STP.002V surveillance procedure in the Master Surveillance Schedule.While recording the completed sections of the surveillance procedure just reviewed, the Unit Supervisor incorrectly recalled that the weekly surveillance section of the procedure had been completed and signed off the weekly surveillance procedure as complete.Following the performance of the surveillances listed on the schedule, the Operations Department Engineering Section conducts a review of the completed surveillance paperwork. | FACILITY NAME (1) DOCKET NUMBKR (2) PAGE (3) | ||
During this surveillance paperwork review, the engineers identified on 4-21-92 that the 1-OHP 4030.STP.002V weekly surveillance procedure sheets were missing.Upon discovering that NRC Form 36SA (689) | LER NUMBER (Sl YEAR II SKDUKNTIAL;~REVISION NUMSSR NVMISII D. C. Cook Nuclear Plant - Unit 1 3 1 5 9 2 0 0 40 0 0 2 OF 0 4 TEXT (Ifmore speceis rer)rrirer( Iree aAiiriorreiiVRC Form JSSAK) (IT) | ||
)AC FORM 3nSA | Conditions Prior to Occurrence Unit one (U-1) in mode one at 89.9X power. | ||
WASHINGTON, DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (3(500(041, OFFICE OF | Unit two (U-2) in mode six at OX power. | ||
DC 20503..FACILITY NAME (1)DOCKET NUMBER (2)LER NUMBER (6)YEAR'jul SEQUENTIAL,g>I(g | Descri tion of Event On 4-20-92, the 1-OHP 4030.STP.002V (Boration System Valve Position Verification and Testing) surveillance procedure was not performed to satisfy the Technical Specification (TS) surveillance requirement 4.1.2.2.a.l for TS 3.1.2.2 (Reactivity Control Systems Flow Paths - Operation). TS 4.1.2.2.a.l requires at least once per seven days that the boration flow paths from the refueling water storage tank (RWST) (EIIS/CB-TK) and the boric acid storage tank (BAST) (EIIS/CB-TK) be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel. | ||
This was based on the engineers'ast experience had shown that the control room operators also track incomplete surveillances and pursue the completion of a surveillance before the grace period expires.Cause of Event The cause for the missed surveillance was personnel error.The Unit Supervisor developed a mind set during the surveillance review that the surveillance was completed and therefore signed off the surveillance procedure as complete on the schedule.In addition, the engineers had a mind set that control room operators record and track surveillances in grace and that the control room operators were aware that the surveillance had not been completed, or that the paperwork must have been routed to the engineers and had not arrived.Therefore, the engineers did not pursue further the completion of the surveillance. | The missed surveillance procedure was discovered by an Operations Department Engineer on 4-24-92, The surveillance test was last performed on 4-13-92. | ||
A~nal sls Technical Specification (TS)4.1.2.2.a.l (Reactivity Control Systems Flow Paths-Operating) requires at least once per seven days the boration flow paths from the refueling water storage tank (RWST)and the boric acid storage tank (BAST)to be proven operable by cycling each testable power-operated or automatic valve in the flow path through at lease one complete cycle of full travel.The failure to perform the surveillance is a violation of Technical Specification 3.1.2.2 and is reportable under 10 CFR 50.73 (a)(2)(i)(B). | The TS action statement was entered at 1255 hours and the 1-OHP 4030.STP.002V surveillance procedure was started, completed, and reviewed by 1314 hours on 4-24-92. A review of the completed surveillance noted that the surveillance acceptance criteria were satisfied and the action statement was exited at this time. | ||
Following the identification of the missed surveillance, the 1-OHP 4030.STP.002V surveillance procedure was performed to satisfy the requirements of TS 4.1.2.2.a.l. | On 4-20-92, the involved Unit Supervisor (Senior Reactor Operator) reviewed the 1-OHP 4030.STP.002V paperwork completed during his shift. Following this review, the Unit Supervisor recorded the completed sections of the 1-OHP 4030.STP.002V surveillance procedure in the Master Surveillance Schedule. | ||
A review of the completed surveillance noted that the requirements of the surveillance procedure were met.Therefore, it is concluded that the valves tested by the surveillance procedure would have performed their safety function if required during the time period from the last completed surveillance procedure on 4-13-92 and the surveillance procedure performed on 4-24-92.NR 0 Form 366A (6419) | While recording the completed sections of the surveillance procedure just reviewed, the Unit Supervisor incorrectly recalled that the weekly surveillance section of the procedure had been completed and signed off the weekly surveillance procedure as complete. | ||
I/RC FOR)4 A | Following the performance of the surveillances listed on the schedule, the Operations Department Engineering Section conducts a review of the completed surveillance paperwork. During this surveillance paperwork review, the engineers identified on 4-21-92 that the 1-OHP 4030.STP.002V weekly surveillance procedure sheets were missing. Upon discovering that NRC Form 36SA (689) | ||
WASHINGTON. | |||
OC 20555.AND TO 1ME PAPERWORK AEDUCTION PAO/ECT (315041041. | )AC FORM 3nSA U.S. NUC(.EAR REGULATORY COMMISSION APPROVEQ 0MB NO. 31500104 (64)9) | ||
OFFICE OF | EXPIRES: 4/30/92 ES ATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVE REPORT (LER) INFORMATION COLLECTION REOUESTI 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (PJ)301. U.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON, DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (3(500(041, OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON. DC 20503. | ||
DC 20503.FACILITY NAME I 1)DOCKET NUMBER (2)LER NUMBER (6)PAGE (3)YEAR PIN | . FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3I YEAR 'jul SEQUENTIAL,g>I(g NUMBSR '..: REVISION MUAISSR D. C. Cook Nuclear TEXT /// more epeoe Ls Je)rrie(L oee ~ Plant - Unit NRC Forrlr 36SA'4) l)7) 1 3 1 5 9 2 0 0 4 0 0 P 30F p the weekly surveillance procedure sheets were missing, the engineers documented that the weekly surveillance procedure was in grace by recording the status in the grace section of the Surveillance Status Summary Report. | ||
The Shift Supervisor reviewed The finding of this investigation with the involved Unit Supervisor. | Although the engineers identified that the weekly surveillance was apparently in grace due to the missing paperwork, the engineers did not pursue further why the surveillance procedure had not been completed. This was based on the engineers'ast experience had shown that the control room operators also track incomplete surveillances and pursue the completion of a surveillance before the grace period expires. | ||
This review included a discussion of the Unit Supervisor responsibility and accountability for the performance and documentation of surveillance procedures. | Cause of Event The cause for the missed surveillance was personnel error. The Unit Supervisor developed a mind set during the surveillance review that the surveillance was completed and therefore signed off the surveillance procedure as complete on the schedule. | ||
The Operations Department Production Supervisor reviewed the finding of this investigation with the engineers involved.Previous Simila Events A review of the License Event Reports did not identify a similar event. | In addition, the engineers had a mind set that control room operators record and track surveillances in grace and that the control room operators were aware that the surveillance had not been completed, or that the paperwork must have been routed to the engineers and had not arrived. Therefore, the engineers did not pursue further the completion of the surveillance. | ||
A~nal sls Technical Specification (TS) 4.1.2.2.a.l (Reactivity Control Systems Flow Paths - Operating) requires at least once per seven days the boration flow paths from the refueling water storage tank (RWST) and the boric acid storage tank (BAST) to be proven operable by cycling each testable power-operated or automatic valve in the flow path through at lease one complete cycle of full travel. The failure to perform the surveillance is a violation of Technical Specification 3.1.2.2 and is reportable under 10 CFR 50.73 (a)(2)(i)(B). | |||
NO DOCKET FACIL:50-315 Donald C.Cook Nuclear Power Plant, Unit 1, Indiana M 05000315 AUTH.NAME AUTHOR AFFILIATION SAMPSON,J.R. | Following the identification of the missed surveillance, the 1-OHP 4030.STP.002V surveillance procedure was performed to satisfy the requirements of TS 4.1.2.2.a.l. A review of the completed surveillance noted that the requirements of the surveillance procedure were met. Therefore, it is concluded that the valves tested by the surveillance procedure would have performed their safety function if required during the time period from the last completed surveillance procedure on 4-13-92 and the surveillance procedure performed on 4-24-92. | ||
Indiana Michigan Power Co.(formerly Indiana 6 Michigan Ele BLIND,A.A. | NR 0 Form 366A (6419) | ||
Indiana Michigan Power Co.(formerly Indiana 6 Michigan Ele RECIP.NAME RECIPIENT AFFILIATION | |||
I/RC FOR)4 A V.S. NUCLEAR REGULATORY COMMISSION (64) 9) APPAOVED OMB NO. 31500104 EXP)RES: 4/30/92 ES i ATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVE REPORT (LER) INFORMATION COLLECTION REQUEST: 508) HAS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TQ TH'E RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (PB30). V.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON. OC 20555. AND TO 1ME PAPERWORK AEDUCTION PAO/ECT (315041041. OFFICE OF MANAGEMENTANO BUDGET, WASHINGTON. DC 20503. | |||
FACILITY NAME I 1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3) | |||
YEAR SEQUENTIAL REVISION PIN NUMBER <I'A NUMBER D. C. Cook Nuclear Plant Unit 1 3 1 5 9 2 0 0 4 0 0 0 4 OF 0 4 TEXT //I IINee epeee le /eeIeeN/ Bee ~ ////Bone/HRC Fem) 366A'4) (17) | |||
Based upon the above analysis, the failure to perform the surveillance procedure within the grace period is not considered to have created a significant safety concern, nor did the missed surveillance create a significant hazard to the health and safety of the general public. | |||
Corrective Action | |||
: 1. Following the identification that the portion of the 1-OHP 4030.STP.002V surveillance procedure had not been performed, the 1-OHP 4030.STP.002V surveillance procedure was satisfactorily completed. | |||
The Shift Supervisor reviewed The finding of this investigation with the involved Unit Supervisor. This review included a discussion of the Unit Supervisor responsibility and accountability for the performance and documentation of surveillance procedures. | |||
The Operations Department Production Supervisor reviewed the finding of this investigation with the engineers involved. | |||
Previous Simila Events A review of the License Event Reports did not identify a similar event. | |||
NRC FomI 366A (64)9) | |||
~ ~ ~ | |||
/6 | |||
ACCELERATED DIS RIBUTION DEMONS TION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS) | |||
ACCESSION NBR:9205270001 DOC.DATE: 92/05/20 NOTARIZED: NO DOCKET FACIL:50-315 Donald C. Cook Nuclear Power Plant, Unit 1, Indiana M 05000315 AUTH. NAME AUTHOR AFFILIATION SAMPSON,J.R. Indiana Michigan Power Co. (formerly Indiana 6 Michigan Ele BLIND,A.A. Indiana Michigan Power Co. (formerly Indiana 6 Michigan Ele RECIP.NAME RECIPIENT AFFILIATION | |||
==SUBJECT:== | ==SUBJECT:== | ||
LER 92-004-00:on 920420,7-day test to prove operability of boration flow paths from refueling water storage 6 boric acid storage tanks not performed as scheduled. | LER 92-004-00:on 920420,7-day test to prove operability of boration flow paths from refueling water storage 6 boric D acid storage tanks not performed as scheduled. Caused by personnel error. Test successfully performed.W/920520 ltr. | ||
Caused by personnel error.Test successfully performed.W/920520 ltr.DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR I ENCL J SIZE: S TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.NOTES: D | DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR I ENCL J SIZE: S TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc. | ||
PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.20079)TO | NOTES: | ||
92-004-00 Sincerely, A.A.Blind Plant Manager/sb Attachment c: D.H.Williams, Jr.A.B.Davis, Region | RECIPIENT COPIES RECIPIENT COPIES D ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD3-1 LA 1 1 PD3-1 PD 1 1 D STANG,J 1 1 INTERNAL'CNW 2 2 AEOD/DOA 1 1 AEOD/DS P/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DET/EMEB 7E 1 1 NRR/DLPQ/LHFB10 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB SD 1 1 NRR/DST/SICBSH3 1 1 NRR S DPLBSD1 1 1 NRR/DST/SRXB SE 1 1 G~EF ILE 02 1 1 RES/DSIR/EIB 1 1 RGN3 01 1 1 EXTERNAL EGGG BRYCE g J ~ H 3 3 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY,G.A 1 1 NSIC POOREgW ~ 1 1 NUDOCS FULL TXT 1 1 D | ||
D D | |||
NOTE TO ALL "RIDS" RECIPIENTS: | |||
PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 20079) TO ELMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED! | |||
FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 30 ENCL 30 | |||
Indiana Michigan Power Company Cook Nuclear Plant One Cook Place | |||
~ | |||
Bridgman, Ml 49106 616 465 5901 INDUNA POPOVER NICMGAM May 20, 1992 United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-58 Docket No. 50-315 Document Control Manager: | |||
In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ort S stem the following report is being submitted: | |||
92-004-00 Sincerely, A. A. Blind Plant Manager | |||
/sb Attachment c: D. H. Williams, Jr. | |||
A. | |||
E. | |||
B. Davis, Region E. Fitzpatrick III P. A. Barrett B. F. Henderson R. F. Kroeger B. Walters Ft. Wayne NRC Resident Inspector J. F. Stang NRC J. G. Keppler M. R. Padgett G. Charnoff, Esq. | |||
D. Hahn INPO S. J. Brewer/B. P. Lauzau B. A. Svensson 920527000i 920520 PDR ADOCK 05000315 S PDR | |||
NRC FORM 346 (64)9) | |||
LICENSEE EVENT REPORT (LER) | |||
V.S. NUCLEAR REGULATORY COMMISSION t APPROVED OMB NO. 31504)104 EXPIRES: 4I30192 ESTIMATED BURDEN PEA RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION AEOUESTt 50.0 HRS. FORWAAD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (PPr30), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET) WASHINGTON, DC 20503. | |||
FACILITYNAME (I) DOCKET NUMBER l2) PAGE. 3 D. C. Cook Nuclear Plant Unit 1 0 5 0 0 0 3 ] 5 1 OF 0 4 TITLE (4) | |||
Missed Surveillance on Boric Acid Flow Path due to Personnel Error During Procedure Review Process EVENT DATE(5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (4) | |||
MONTH OAY YEAR YEAR SEOVENTIAL opn MONTH DAY YEAR FACILITYNAMES DOCKET NUMBER(SI NVMSEA NVMSESI 0 5 0 0 0 0 4 2 0 9 2 9 2 0 0 4 0 0 0 5 2 0 9 2 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT TO THE REOUIREMENTS OF 10 CFR g: (Cn<<4 onr or morr of tnr IollowinPI (11) | |||
OPERATING MODE (Sl j 20802(S) 20AOS(c) 50.73(e) (2) liv) 73.71(S) | |||
POWE R 20.4061 ~ ) Ill(il 50.34(cl(1) 50.73( ~ )(2)(vl 73.71(cl LEYEL 8 9 9 20.405(e I (1 l(ii) 50.34(cl(2) S0,73( ~ ) LE I(viil DTHER (speedy sn Aostrrct Orlrvvrmlin Trit, NRC Form 20.406( ~ )(1)(15) X 60.73( ~ )(2)ill 60.73(e) (2) (viii)(A) 388AI 20AOS(el(1 l(ivt 50,73(e)(2) liil 50.73(el(2)(viiil(BI | |||
))Wv@~< 20.405(el(1) lvl 50.73(e)(2((iil) 60.73 ( ~ I (2) (el LICENSEE CONTACT FOR THIS LEA (12I NAME TELEPHONE NUMBER AREA CODE J. R. Sampson, Operations Department COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS AEPOAT 113) 616465-5901 MANUFAC. EPORTABLE MANUFAC-CAUSE SYSTEM COMPONENT CAUSE SYSTEM COMPONENT TVRER TO NPADS aI(SI~BP; TIJRER | |||
~OP)BI Ln'(IQ<".4 klan%~'~ | |||
SVPPLEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR EXPECTED SUBMISSION DATE (15) | |||
YES llf yrs, complrtr EXPECTED SIIEMISSIOII DATEJ NO ABsTRAcT (Limit to f400 sprees, I r., rppioxlmrtrlp liltrrn slnclr spree tvprwri ttrn linrsl (14) | |||
On 4-20-92, contrary to Technical Specification (TS) 4.1.2.2.a.l, the seven-day test to prove the operability of the boration flow paths from the refueling water storage tank and the boric acid storage tank was not performed as scheduled. The test is accomplished by cycling each testable power-operated or automatic 'valve in the flow path through at least one complete cycle of full travel. The missed surveillance was identified on 4-24-92. The surveillance procedure was immediately performed. All test acceptance criteria were met. The missed surveillance occurred as a result of personnel error during the review process. | |||
The findings of this event were reviewed with the involved personnel by their supervisors. | |||
NRC Fosses 346 (64)9) | |||
NRC FORM 366A (64)9) | |||
LICENSEE EVENT REPORT (LER) | |||
TEXT CONTINUATION U.S. NUCLEAR REGULATORY COMMISSION t APPROVED OMB NO. 31504104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P.530), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON. DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503. | |||
FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3) | |||
SEQUENTIAL REVISION YEAR NUMBER NVMBER D. C. Cook Nuclear Plant Unit 1 0 5 0 0 0 3 ] 5 9 0 0 4 0 0 0 2 QF 0 TEXT ///moro 4O4co /4 roqo/rod, IrJo odds/orM/HRC Form 36649/ (17) | |||
Conditions Prior to Occurrence Unit one (U-1) in mode one at 89.9X power. | |||
Unit two (U-2) in mode six at OX power. | |||
Descri tion of Event On 4-20-92, the 1-OHP 4030.STP.002V (Boration System Valve Position Verification and Testing) surveillance procedure was not performed to satisfy the Technical Specification (TS) surveillance requirement 4.1.2.2.a.l for TS 3.1.2.2 (Reactivity Control Systems Flow Paths - Operation). TS 4.1.2.2.a.l requires at least once per seven days that the boration flow paths from the refueling water storage tank (RWST) (EIIS/CB-TK) and the boric acid storage tank (BAST) (EIIS/CB-TK) be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel. | |||
The missed surveillance procedure was discovered by an Operations Department Engineer on 4-24-92. The surveillance test was last performed on 4-13-92. | |||
The TS action statement was entered at 1255 hours and the 1-OHP 4030.STP.002V surveillance procedure was started, completed, and reviewed by 1314 hours on 4-24-92. A review of the completed surveillance noted that the surveillance acceptance criteria were satisfied and the action statement was exited at this time. | |||
On 4-20-92, the involved Unit Supervisor (Senior Reactor Operator) reviewed the 1-OHP 4030.STP.002V paperwork completed during his shift. Following this review, the Unit Supervisor recorded the completed sections of the 1-OHP 4030.STP.002V surveillance procedure in the Master Surveillance Schedule. | |||
While recording the completed sections of the surveillance procedure just reviewed, the Unit Supervisor incorrectly recalled that the weekly surveillance section of the procedure had been completed and signed off the weekly surveillance procedure as complete. | |||
Following the performance of the surveillances listed on the schedule, the Operations Department Engineering Section conducts a review of the completed surveillance paperwork. During this surveillance paperwork review, the engineers identified on 4-21-92 that the 1-OHP 4030.STP.002V weekly surveillance procedure sheets were missing. Upon discovering that NR C Form 366A (64)9) | |||
NRC FORM 366A U IL NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 31500104 (64)9) EXPIRESI 4/30/92 ESTI ED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVEN EPORT (LER) INFORMATION COLLECTION REQUEST: 50.0 HAS, FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P-530). V.S. NVCI.EAR REGULATORY COMMISSION, WASHINGTON. DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503. | |||
FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3) | |||
SEOVENTIAL REVISION YEAR NUMSER NUMBER D. C. Cook Nuclear Plant Unit 1 0 5 0 0 0 3 ] 5 9 2 0 0 4 0 0 0 3 QF 0 TEXT /l/ moro Epoco /1 rorlur)od, uro oddldooo/ NRC Form 3664 9/ 07) the weekly surveillance procedure sheets were missing, the engineers documented that the weekly surveillance procedure was in grace by recording the status in the grace section of the Surveillance Status Summary Report. | |||
Although the engineers identified that the weekly surveillance was apparently in grace due to the missing paperwork, the engineers did not pursue further why the surveillance procedure had not been completed. This was based on the engineers'ast experience had shown that the control room operators also track incomplete surveillances and pursue the completion of a surveillance before the grace period expires. | |||
Cause of Event The cause for the missed surveillance was personnel error. The Unit Supervisor developed a mind set during the surveillance review that the surveillance was completed and therefore signed off the surveillance procedure as complete on the schedule. | |||
In addition, the engineers had a mind set that control room operators record and track surveillances in grace and that the control room operators were aware that the surveillance had not been completed, or that the paperwork must have been routed to the engineers and had not arrived. Therefore, the engineers did not pursue further the completion of the surveillance. | |||
A~nal sis Technical Specification (TS) 4.1.2.2.a.l (Reactivity Control Systems Flow Paths - Operating) requires at least once per seven days the boration flow paths from the refueling water storage tank (RWST) and the boric acid storage tank (BAST) to be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel. The failure to perform the surveillance is a violation of Technical Specification 3.1.2.2 and is reportable under 10 CFR 50s73 (a)(2)(i)(B). | |||
Following the identification of the missed surveillance, the 1-OHP 4030.STP.002V surveillance procedure was performed to satisfy the requirements of TS 4.1.2.2.a.l. A review of the completed surveillance noted that the requirements of the surveillance procedure were met. Therefore, it is concluded that the valves tested by the surveillance procedure would have performed their safety function if required during the time period from the last completed surveillance procedure on 4-13-92 and the surveillance procedure performed on 4-24-92. | |||
NAC Form 366A (84)9) | |||
NRC FORM | NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 31504(04 (64) 9) | ||
EXPIRESI 4/30/02 ESTI FD BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVEN EPORT (LER) INFORMATION COLLECTION REQUEST: 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P430), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503. | |||
FACILITY NAME (1) ~ DOCKET NUMBER (2) LER NUMBER (6) PAGE (3) | |||
YEAR SEQUENTIAI. 5+( REVISION NUMBER NUMBER D. C. Cook Nuclear Plant Unit 1 3 1 5 9 2 0 0 4 0 0 0 40F 0 TEXT N mort trrtct is ttqur)td, u>> 4ddrrr'ootr HRC Form 3664'tl l)7) | |||
Based upon the above analysis, the failure to perform the surveillance procedure within the grace period is not considered to have created a significant safety concern, nor did the missed surveillance create a significant hazard to the health and safety of the general public. | |||
Corrective Action Following the identification that the portion of the 1-OHP 4030.STP.002V surveillance procedure had not been performed, the 1-OHP 4030 STP.002V ~ | |||
surveillance procedure was satisfactorily completed. | |||
DC 20555, AND TO | : 2. The Shift Supervisor reviewed The finding of this investigation with the involved Unit Supervisor. This review included a discussion of the Unit Supervisor responsibility and accountability for the performance and documentation of surveillance procedures. | ||
: 3. The Operations Department Production Supervisor, reviewed the finding of this .investigation with the engineers involved. | |||
Previous Similar Events A review of the License Event Reports did not identify a similar event. | |||
NRC Form 366A (64)B)}} | |||
2.The Shift Supervisor reviewed The finding of this investigation with the involved Unit Supervisor. | |||
This review included a discussion of the Unit Supervisor responsibility and accountability for the performance and documentation of surveillance procedures. | |||
3.The Operations Department Production Supervisor, reviewed the finding of this.investigation with the engineers involved.Previous Similar Events A review of the License Event Reports did not identify a similar event.NRC Form 366A (64)B)}} | |||
Latest revision as of 01:41, 4 February 2020
| ML17329A515 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 05/20/1992 |
| From: | Blind A, Sampson J INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LER-92-004-01, LER-92-4-1, NUDOCS 9205270001 | |
| Download: ML17329A515 (13) | |
Text
1
!ndiana Michigan Power Company Cook Nuc!ear P!ant
".ne Cook Place Bridgman. Ml ~9106 616 465 5901 diag INDIANJL NlCHlG4N POWER May 20, 1992 United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-58 Docket No. 50-315 Document Control Manager:
ln accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ort S stem the following report is being submitted:
92-004-00 Sincerely, A. A. Blind Plant Manager
/sb Attachment c D. H. Williams, Jr.
tA. B.. Davis., Region~?
E. Fitzpatrick Q'.
P. A. Barrett B. F. Henderson R. F. Kroeger B. Walters Ft. Wayne NRC Resident Inspector J. F. Stang NRC J. G. Keppler M. R. Padgett G. Charnoff, Escr.
D. Hahn XNPO S. J. Brewer/B. P. Lauzau B. A. Svensson gAN g 61SR Q'c Oyga
NRC FORM 366 V S. NUCLEAR REGULATORY COMMISSION (649) APPROVED 0MB NO. 3150410C EXPIRES: C/30I92 ESTIMATED BURDEN PER RESPONSE TO COLIPLY WTH THIS INFORMATION COLLECTION REOUEST. 500 HRS. FORWARD LICENSEE EVENT REPORT (LER) COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMFNT BRANCH (F630), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON. DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31$ 0C)10el. OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON. DC 20503.
FACILITY NAME lll DOCKET NUMBER (2) PA E 3 D. C. Cook Nuclear Plant Unit 1 0 5 0 0 0 3 1 5 1 OF 0 4 TITLE Icl Missed Surveillance on Boric Acid Flow Path due to Personnel Error During Procedure Review Process EVENT OATK (5) LER NUMBER LSI REPORT DATE (7) OTHER FACILITIES INVOLVED (4)
SEOVENTIAL REVOKE FACILITYNAMES DOCKET NUMBFR(SI MONTH OAY YEAR YEAR NVMSEII NVMSEII MON)'H OAY YEAR 0 5 0 0 0 04209292 0 0 4 0 0 0 5 THIS REPORT IS SUBMITTED PURSUANT T0 THE R SOU(A EMENTS OF 10 2 0 9 2 C FR (): IC>rrCC Onr Or mrrr Of tnr fOIIOwinpl (11 0 5 0 0 0 OPERATING MODE (4) 20A02(SI 20AOS(cl 50.73(el(2IGrl 73.71(SI POWER 20A05(e) ()Ill) 50M(el)1) 60.73(el(2) (r I 73.7((c)
LEYEL, cR ~ 'ro"'C 8 9 9 20A054)(1l(EI 20AOS(e) (I ) (IIII 50.34(c)(2) 50.73(e)(2) lll 50.7 3 4l(2Hrii) 60.73(e)12) (rill)I Al OTHER ISorc>fy >n Aottrrct Oelow rnrf In Fret, HAC Form SSSA>
V 20A05 4) (1 ) tlrl 60 7 34) l2) (9) 50.73 4 I (2 I 4lil ) I 5 I
)O; r . carr.@ 20.4054)(1 I (rl 50.73 Iel(2)(lli) 50,7S( ~ ) IS)(el LICENSEE CONTACT FOR THIS LER (12)
NAME TELEPHONE NUMBER AREA CODE J. R. Sampson, Operations Department COMPLETE ON! LINE FOR EACH COIAPONENT FAILURE DESCRIBED IH THIS REPORT IIS) 616465-5901 CAUSE SYSTEM COMPONENT MANUFAC.
TUAER FPOATABLF.
TO NPAOS
~~Xo .. r;rl CAUSE SYSTEM COMPONENT MANUFAC.
TUREA EPOATABL TO NPAOS k~m c
@o~5 SUPPLEMENTAL REPORT EXPECTED IICI MONTH DAY YEAR EXPECTED SUBMISSION DATE (15)
YES llfyrt, compirtr EXPECPEI> SVSMISSION DATEI NO ABSTRACT l(,lmit to tc00 torcrL I r., rpproelmrtrly lilrrrn tinplr tprtr tyPrwnttrn linwl l14)
On 4-20-92, contrary to Technical Specification (TS) 4.1.2.2.a.l, the seven-day test to prove the operability of the boration flow paths from the refueling water storage tank and the boric acid storage tank was not performed as scheduled. The test is accomplished by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel. The missed surveillance was identified on 4-24-92. The surveillance procedure was immediately performed. All test acceptance criteria were met. The missed surveillance occurred as a result of personnel error during the review process.
The findings of this event were reviewed with the involved personnel by their supervisors.
NRC Form 344 (649)
NRC FORM 3rrSA (689)
LICENSEE EVE TEXT CONTINUATION U.S. NUCLEAR REGULATORY COMMISSION REPORT (LERI t APPROVED OMB NOr 31504104 EXPIRES: rU30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 500 HRS. FORWARD COMMENTS RFGARDING BURDEN ESTIMATE TO THE RECORDS ANO REPORTS MANAGEMENT BRANCH (P430). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, ANO TO 1NE PAPERWORK REDUCTION PROJECT (3)500104), OFFICE OF MANAGEMENTANO BUDGET, WASHINGTON. DC 20503.
FACILITY NAME (1) DOCKET NUMBKR (2) PAGE (3)
LER NUMBER (Sl YEAR II SKDUKNTIAL;~REVISION NUMSSR NVMISII D. C. Cook Nuclear Plant - Unit 1 3 1 5 9 2 0 0 40 0 0 2 OF 0 4 TEXT (Ifmore speceis rer)rrirer( Iree aAiiriorreiiVRC Form JSSAK) (IT)
Conditions Prior to Occurrence Unit one (U-1) in mode one at 89.9X power.
Unit two (U-2) in mode six at OX power.
Descri tion of Event On 4-20-92, the 1-OHP 4030.STP.002V (Boration System Valve Position Verification and Testing) surveillance procedure was not performed to satisfy the Technical Specification (TS) surveillance requirement 4.1.2.2.a.l for TS 3.1.2.2 (Reactivity Control Systems Flow Paths - Operation). TS 4.1.2.2.a.l requires at least once per seven days that the boration flow paths from the refueling water storage tank (RWST) (EIIS/CB-TK) and the boric acid storage tank (BAST) (EIIS/CB-TK) be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.
The missed surveillance procedure was discovered by an Operations Department Engineer on 4-24-92, The surveillance test was last performed on 4-13-92.
The TS action statement was entered at 1255 hours0.0145 days <br />0.349 hours <br />0.00208 weeks <br />4.775275e-4 months <br /> and the 1-OHP 4030.STP.002V surveillance procedure was started, completed, and reviewed by 1314 hours0.0152 days <br />0.365 hours <br />0.00217 weeks <br />4.99977e-4 months <br /> on 4-24-92. A review of the completed surveillance noted that the surveillance acceptance criteria were satisfied and the action statement was exited at this time.
On 4-20-92, the involved Unit Supervisor (Senior Reactor Operator) reviewed the 1-OHP 4030.STP.002V paperwork completed during his shift. Following this review, the Unit Supervisor recorded the completed sections of the 1-OHP 4030.STP.002V surveillance procedure in the Master Surveillance Schedule.
While recording the completed sections of the surveillance procedure just reviewed, the Unit Supervisor incorrectly recalled that the weekly surveillance section of the procedure had been completed and signed off the weekly surveillance procedure as complete.
Following the performance of the surveillances listed on the schedule, the Operations Department Engineering Section conducts a review of the completed surveillance paperwork. During this surveillance paperwork review, the engineers identified on 4-21-92 that the 1-OHP 4030.STP.002V weekly surveillance procedure sheets were missing. Upon discovering that NRC Form 36SA (689)
)AC FORM 3nSA U.S. NUC(.EAR REGULATORY COMMISSION APPROVEQ 0MB NO. 31500104 (64)9)
EXPIRES: 4/30/92 ES ATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVE REPORT (LER) INFORMATION COLLECTION REOUESTI 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (PJ)301. U.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON, DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (3(500(041, OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON. DC 20503.
. FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3I YEAR 'jul SEQUENTIAL,g>I(g NUMBSR '..: REVISION MUAISSR D. C. Cook Nuclear TEXT /// more epeoe Ls Je)rrie(L oee ~ Plant - Unit NRC Forrlr 36SA'4) l)7) 1 3 1 5 9 2 0 0 4 0 0 P 30F p the weekly surveillance procedure sheets were missing, the engineers documented that the weekly surveillance procedure was in grace by recording the status in the grace section of the Surveillance Status Summary Report.
Although the engineers identified that the weekly surveillance was apparently in grace due to the missing paperwork, the engineers did not pursue further why the surveillance procedure had not been completed. This was based on the engineers'ast experience had shown that the control room operators also track incomplete surveillances and pursue the completion of a surveillance before the grace period expires.
Cause of Event The cause for the missed surveillance was personnel error. The Unit Supervisor developed a mind set during the surveillance review that the surveillance was completed and therefore signed off the surveillance procedure as complete on the schedule.
In addition, the engineers had a mind set that control room operators record and track surveillances in grace and that the control room operators were aware that the surveillance had not been completed, or that the paperwork must have been routed to the engineers and had not arrived. Therefore, the engineers did not pursue further the completion of the surveillance.
A~nal sls Technical Specification (TS) 4.1.2.2.a.l (Reactivity Control Systems Flow Paths - Operating) requires at least once per seven days the boration flow paths from the refueling water storage tank (RWST) and the boric acid storage tank (BAST) to be proven operable by cycling each testable power-operated or automatic valve in the flow path through at lease one complete cycle of full travel. The failure to perform the surveillance is a violation of Technical Specification 3.1.2.2 and is reportable under 10 CFR 50.73 (a)(2)(i)(B).
Following the identification of the missed surveillance, the 1-OHP 4030.STP.002V surveillance procedure was performed to satisfy the requirements of TS 4.1.2.2.a.l. A review of the completed surveillance noted that the requirements of the surveillance procedure were met. Therefore, it is concluded that the valves tested by the surveillance procedure would have performed their safety function if required during the time period from the last completed surveillance procedure on 4-13-92 and the surveillance procedure performed on 4-24-92.
NR 0 Form 366A (6419)
I/RC FOR)4 A V.S. NUCLEAR REGULATORY COMMISSION (64) 9) APPAOVED OMB NO. 31500104 EXP)RES: 4/30/92 ES i ATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVE REPORT (LER) INFORMATION COLLECTION REQUEST: 508) HAS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TQ TH'E RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (PB30). V.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON. OC 20555. AND TO 1ME PAPERWORK AEDUCTION PAO/ECT (315041041. OFFICE OF MANAGEMENTANO BUDGET, WASHINGTON. DC 20503.
FACILITY NAME I 1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
YEAR SEQUENTIAL REVISION PIN NUMBER <I'A NUMBER D. C. Cook Nuclear Plant Unit 1 3 1 5 9 2 0 0 4 0 0 0 4 OF 0 4 TEXT //I IINee epeee le /eeIeeN/ Bee ~ ////Bone/HRC Fem) 366A'4) (17)
Based upon the above analysis, the failure to perform the surveillance procedure within the grace period is not considered to have created a significant safety concern, nor did the missed surveillance create a significant hazard to the health and safety of the general public.
Corrective Action
- 1. Following the identification that the portion of the 1-OHP 4030.STP.002V surveillance procedure had not been performed, the 1-OHP 4030.STP.002V surveillance procedure was satisfactorily completed.
The Shift Supervisor reviewed The finding of this investigation with the involved Unit Supervisor. This review included a discussion of the Unit Supervisor responsibility and accountability for the performance and documentation of surveillance procedures.
The Operations Department Production Supervisor reviewed the finding of this investigation with the engineers involved.
Previous Simila Events A review of the License Event Reports did not identify a similar event.
NRC FomI 366A (64)9)
~ ~ ~
/6
ACCELERATED DIS RIBUTION DEMONS TION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
ACCESSION NBR:9205270001 DOC.DATE: 92/05/20 NOTARIZED: NO DOCKET FACIL:50-315 Donald C. Cook Nuclear Power Plant, Unit 1, Indiana M 05000315 AUTH. NAME AUTHOR AFFILIATION SAMPSON,J.R. Indiana Michigan Power Co. (formerly Indiana 6 Michigan Ele BLIND,A.A. Indiana Michigan Power Co. (formerly Indiana 6 Michigan Ele RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
LER 92-004-00:on 920420,7-day test to prove operability of boration flow paths from refueling water storage 6 boric D acid storage tanks not performed as scheduled. Caused by personnel error. Test successfully performed.W/920520 ltr.
DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR I ENCL J SIZE: S TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.
NOTES:
RECIPIENT COPIES RECIPIENT COPIES D ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD3-1 LA 1 1 PD3-1 PD 1 1 D STANG,J 1 1 INTERNAL'CNW 2 2 AEOD/DOA 1 1 AEOD/DS P/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DET/EMEB 7E 1 1 NRR/DLPQ/LHFB10 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB SD 1 1 NRR/DST/SICBSH3 1 1 NRR S DPLBSD1 1 1 NRR/DST/SRXB SE 1 1 G~EF ILE 02 1 1 RES/DSIR/EIB 1 1 RGN3 01 1 1 EXTERNAL EGGG BRYCE g J ~ H 3 3 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY,G.A 1 1 NSIC POOREgW ~ 1 1 NUDOCS FULL TXT 1 1 D
D D
NOTE TO ALL "RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 20079) TO ELMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!
FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 30 ENCL 30
Indiana Michigan Power Company Cook Nuclear Plant One Cook Place
~
Bridgman, Ml 49106 616 465 5901 INDUNA POPOVER NICMGAM May 20, 1992 United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-58 Docket No. 50-315 Document Control Manager:
In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ort S stem the following report is being submitted:
92-004-00 Sincerely, A. A. Blind Plant Manager
/sb Attachment c: D. H. Williams, Jr.
A.
E.
B. Davis, Region E. Fitzpatrick III P. A. Barrett B. F. Henderson R. F. Kroeger B. Walters Ft. Wayne NRC Resident Inspector J. F. Stang NRC J. G. Keppler M. R. Padgett G. Charnoff, Esq.
D. Hahn INPO S. J. Brewer/B. P. Lauzau B. A. Svensson 920527000i 920520 PDR ADOCK 05000315 S PDR
NRC FORM 346 (64)9)
LICENSEE EVENT REPORT (LER)
V.S. NUCLEAR REGULATORY COMMISSION t APPROVED OMB NO. 31504)104 EXPIRES: 4I30192 ESTIMATED BURDEN PEA RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION AEOUESTt 50.0 HRS. FORWAAD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (PPr30), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET) WASHINGTON, DC 20503.
FACILITYNAME (I) DOCKET NUMBER l2) PAGE. 3 D. C. Cook Nuclear Plant Unit 1 0 5 0 0 0 3 ] 5 1 OF 0 4 TITLE (4)
Missed Surveillance on Boric Acid Flow Path due to Personnel Error During Procedure Review Process EVENT DATE(5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (4)
MONTH OAY YEAR YEAR SEOVENTIAL opn MONTH DAY YEAR FACILITYNAMES DOCKET NUMBER(SI NVMSEA NVMSESI 0 5 0 0 0 0 4 2 0 9 2 9 2 0 0 4 0 0 0 5 2 0 9 2 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT TO THE REOUIREMENTS OF 10 CFR g: (Cn<<4 onr or morr of tnr IollowinPI (11)
OPERATING MODE (Sl j 20802(S) 20AOS(c) 50.73(e) (2) liv) 73.71(S)
POWE R 20.4061 ~ ) Ill(il 50.34(cl(1) 50.73( ~ )(2)(vl 73.71(cl LEYEL 8 9 9 20.405(e I (1 l(ii) 50.34(cl(2) S0,73( ~ ) LE I(viil DTHER (speedy sn Aostrrct Orlrvvrmlin Trit, NRC Form 20.406( ~ )(1)(15) X 60.73( ~ )(2)ill 60.73(e) (2) (viii)(A) 388AI 20AOS(el(1 l(ivt 50,73(e)(2) liil 50.73(el(2)(viiil(BI
))Wv@~< 20.405(el(1) lvl 50.73(e)(2((iil) 60.73 ( ~ I (2) (el LICENSEE CONTACT FOR THIS LEA (12I NAME TELEPHONE NUMBER AREA CODE J. R. Sampson, Operations Department COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS AEPOAT 113) 616465-5901 MANUFAC. EPORTABLE MANUFAC-CAUSE SYSTEM COMPONENT CAUSE SYSTEM COMPONENT TVRER TO NPADS aI(SI~BP; TIJRER
~OP)BI Ln'(IQ<".4 klan%~'~
SVPPLEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR EXPECTED SUBMISSION DATE (15)
YES llf yrs, complrtr EXPECTED SIIEMISSIOII DATEJ NO ABsTRAcT (Limit to f400 sprees, I r., rppioxlmrtrlp liltrrn slnclr spree tvprwri ttrn linrsl (14)
On 4-20-92, contrary to Technical Specification (TS) 4.1.2.2.a.l, the seven-day test to prove the operability of the boration flow paths from the refueling water storage tank and the boric acid storage tank was not performed as scheduled. The test is accomplished by cycling each testable power-operated or automatic 'valve in the flow path through at least one complete cycle of full travel. The missed surveillance was identified on 4-24-92. The surveillance procedure was immediately performed. All test acceptance criteria were met. The missed surveillance occurred as a result of personnel error during the review process.
The findings of this event were reviewed with the involved personnel by their supervisors.
NRC Fosses 346 (64)9)
NRC FORM 366A (64)9)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION U.S. NUCLEAR REGULATORY COMMISSION t APPROVED OMB NO. 31504104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P.530), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON. DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.
FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
SEQUENTIAL REVISION YEAR NUMBER NVMBER D. C. Cook Nuclear Plant Unit 1 0 5 0 0 0 3 ] 5 9 0 0 4 0 0 0 2 QF 0 TEXT ///moro 4O4co /4 roqo/rod, IrJo odds/orM/HRC Form 36649/ (17)
Conditions Prior to Occurrence Unit one (U-1) in mode one at 89.9X power.
Unit two (U-2) in mode six at OX power.
Descri tion of Event On 4-20-92, the 1-OHP 4030.STP.002V (Boration System Valve Position Verification and Testing) surveillance procedure was not performed to satisfy the Technical Specification (TS) surveillance requirement 4.1.2.2.a.l for TS 3.1.2.2 (Reactivity Control Systems Flow Paths - Operation). TS 4.1.2.2.a.l requires at least once per seven days that the boration flow paths from the refueling water storage tank (RWST) (EIIS/CB-TK) and the boric acid storage tank (BAST) (EIIS/CB-TK) be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.
The missed surveillance procedure was discovered by an Operations Department Engineer on 4-24-92. The surveillance test was last performed on 4-13-92.
The TS action statement was entered at 1255 hours0.0145 days <br />0.349 hours <br />0.00208 weeks <br />4.775275e-4 months <br /> and the 1-OHP 4030.STP.002V surveillance procedure was started, completed, and reviewed by 1314 hours0.0152 days <br />0.365 hours <br />0.00217 weeks <br />4.99977e-4 months <br /> on 4-24-92. A review of the completed surveillance noted that the surveillance acceptance criteria were satisfied and the action statement was exited at this time.
On 4-20-92, the involved Unit Supervisor (Senior Reactor Operator) reviewed the 1-OHP 4030.STP.002V paperwork completed during his shift. Following this review, the Unit Supervisor recorded the completed sections of the 1-OHP 4030.STP.002V surveillance procedure in the Master Surveillance Schedule.
While recording the completed sections of the surveillance procedure just reviewed, the Unit Supervisor incorrectly recalled that the weekly surveillance section of the procedure had been completed and signed off the weekly surveillance procedure as complete.
Following the performance of the surveillances listed on the schedule, the Operations Department Engineering Section conducts a review of the completed surveillance paperwork. During this surveillance paperwork review, the engineers identified on 4-21-92 that the 1-OHP 4030.STP.002V weekly surveillance procedure sheets were missing. Upon discovering that NR C Form 366A (64)9)
NRC FORM 366A U IL NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 31500104 (64)9) EXPIRESI 4/30/92 ESTI ED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVEN EPORT (LER) INFORMATION COLLECTION REQUEST: 50.0 HAS, FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P-530). V.S. NVCI.EAR REGULATORY COMMISSION, WASHINGTON. DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.
FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
SEOVENTIAL REVISION YEAR NUMSER NUMBER D. C. Cook Nuclear Plant Unit 1 0 5 0 0 0 3 ] 5 9 2 0 0 4 0 0 0 3 QF 0 TEXT /l/ moro Epoco /1 rorlur)od, uro oddldooo/ NRC Form 3664 9/ 07) the weekly surveillance procedure sheets were missing, the engineers documented that the weekly surveillance procedure was in grace by recording the status in the grace section of the Surveillance Status Summary Report.
Although the engineers identified that the weekly surveillance was apparently in grace due to the missing paperwork, the engineers did not pursue further why the surveillance procedure had not been completed. This was based on the engineers'ast experience had shown that the control room operators also track incomplete surveillances and pursue the completion of a surveillance before the grace period expires.
Cause of Event The cause for the missed surveillance was personnel error. The Unit Supervisor developed a mind set during the surveillance review that the surveillance was completed and therefore signed off the surveillance procedure as complete on the schedule.
In addition, the engineers had a mind set that control room operators record and track surveillances in grace and that the control room operators were aware that the surveillance had not been completed, or that the paperwork must have been routed to the engineers and had not arrived. Therefore, the engineers did not pursue further the completion of the surveillance.
A~nal sis Technical Specification (TS) 4.1.2.2.a.l (Reactivity Control Systems Flow Paths - Operating) requires at least once per seven days the boration flow paths from the refueling water storage tank (RWST) and the boric acid storage tank (BAST) to be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel. The failure to perform the surveillance is a violation of Technical Specification 3.1.2.2 and is reportable under 10 CFR 50s73 (a)(2)(i)(B).
Following the identification of the missed surveillance, the 1-OHP 4030.STP.002V surveillance procedure was performed to satisfy the requirements of TS 4.1.2.2.a.l. A review of the completed surveillance noted that the requirements of the surveillance procedure were met. Therefore, it is concluded that the valves tested by the surveillance procedure would have performed their safety function if required during the time period from the last completed surveillance procedure on 4-13-92 and the surveillance procedure performed on 4-24-92.
NAC Form 366A (84)9)
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 31504(04 (64) 9)
EXPIRESI 4/30/02 ESTI FD BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVEN EPORT (LER) INFORMATION COLLECTION REQUEST: 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P430), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.
FACILITY NAME (1) ~ DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
YEAR SEQUENTIAI. 5+( REVISION NUMBER NUMBER D. C. Cook Nuclear Plant Unit 1 3 1 5 9 2 0 0 4 0 0 0 40F 0 TEXT N mort trrtct is ttqur)td, u>> 4ddrrr'ootr HRC Form 3664'tl l)7)
Based upon the above analysis, the failure to perform the surveillance procedure within the grace period is not considered to have created a significant safety concern, nor did the missed surveillance create a significant hazard to the health and safety of the general public.
Corrective Action Following the identification that the portion of the 1-OHP 4030.STP.002V surveillance procedure had not been performed, the 1-OHP 4030 STP.002V ~
surveillance procedure was satisfactorily completed.
- 2. The Shift Supervisor reviewed The finding of this investigation with the involved Unit Supervisor. This review included a discussion of the Unit Supervisor responsibility and accountability for the performance and documentation of surveillance procedures.
- 3. The Operations Department Production Supervisor, reviewed the finding of this .investigation with the engineers involved.
Previous Similar Events A review of the License Event Reports did not identify a similar event.
NRC Form 366A (64)B)