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=Text=
{{#Wiki_filter:1~'EGUL.Y INFORNATION DISTRIBUTI SYSTEM (RIDS)'ACCESSION NBR: 8711300193 DOC.DATE: 87/11/24, NOTARIZED:
{{#Wiki_filter:'EGUL 1
NO DOCKET¹FACIL: BTN-50-528 Palo Verde Nuclear Stations Unit ii Arizona Publi 05000528 AUTH.NANE AUTHOR AFFILIATION B R*D I SH a T.R.Arizona Nuclear Poeer ProJect (formerly Arizona Public Serv HAYNES'.G.Arizona Nuclear Poeer Pro Ject (formerly Arizona Public Serv REC IP.N*ME RECIPIENT AFFILIATION
    ~
                                  . Y INFORNATION DISTRIBUTI           SYSTEM (RIDS)
  'ACCESSION NBR: 8711300193               DOC. DATE:   87/11/24,   NOTARIZED: NO         DOCKET ¹ FACIL: BTN-50-528 Palo Verde Nuclear Stations                 Unit ii Arizona Publi 05000528 AUTH. NANE           AUTHOR AFFILIATION I
B R*D SH a T. R .     Arizona Nuclear Poeer ProJect (formerly Arizona Public Serv HAYNES'. G.           Arizona Nuclear Poeer Pro Ject (formerly Arizona Public Serv REC IP. N*ME         RECIPIENT AFFILIATION


==SUBJECT:==
==SUBJECT:==
LER 87-026-00:
LER   87-026-00: on 871027'utomatic actuation of balance of plant ESF occurred due to inadvertent containment purge isolated actuation signal. Caused bg personnel error.
on 871027'utomatic actuation of balance of plant ESF occurred due to inadvertent containment purge isolated actuation signal.Caused bg personnel error.Responsible individual mill be reinstructed.
Responsible individual mill be reinstructed. W/871124 ltr.
W/871124 ltr.DISTRIBUTION CODE: IE22D COPIES RECEIVED: LTR J ENCL J.SIZE: TITLE: 50.73 Licensee Event Report (LER)i Incident Rpti etc.NOTES: Standardized plant.05000528 RECIPIENT ID CODE/NAME PD5 LA LIC ITRA.E CQP IES LTTR ENCL 1 1 1 1 REC IP IENT ID CODE/NANE PD5 PD DAVIS'CQP IES LTTR ENCL 1 1 1 1 INTERNAL: ACRS NICHELSON AEOD/DOA AEOD/DSP/ROAB ARM/DCTS/DAB NRR/DEST/ADB NRR/DEBT/ELB.
DISTRIBUTION CODE:       IE22D     COPIES RECEIVED: LTR TITLE: 50. 73 Licensee Event Report (LER)i J    ENCL J.
NRR/DEBT/NEB NRR/DEST/PSB
Incident Rpti etc.
.NRR/DEBT/SGB NRR/DLPG/GAB NRR/DREP/RAB NRR/D IS/SIB LE 02 Di J RGN5 FILE 01 EXTERNAL: EQ8cG QROHi N LPDR NSIC HARRIS'.1 1 1 1 2 2 1 1 0:1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 5 1 1 1*CRB NOELLER AEQD/DSP/NAS.AEQD/DSP/TPAB DEDRO NRR/DEST/CEB NRR/DEST/ICSB NRR/DEST/MTB NRR/DEST/RBB NRR/DLPG/HFB NRR/DOEA/E*B NRR/DREP/RPB NRR/PNAS/ILRB RES DEPY GI RES/DE/EIB H ST LOBBY WARD NRC PDR NSIC MAYSi G 2 2 1 1 1 1 1 1 1 1 1'1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 NOTES: 1 1 TOT*L NUNBER OF COPIES REQUIRED: LTTR 47 ENCL'6 li l NRC Fotm 355 (9 83)LICENSEE EVENT REPORT ILER)UA.NUCLEAR REOULATORY COMMISSION APPROVED OMB NOr 3150010(EXPIRES: SISIISS FACILITY NAME HI DOCKET NUMBER (2)I'A TITLE Iel Palo Verde Unit 1 05000528>oFp3 Automatic Actuation of an En ineered Safet Feature Due to Personnel Error EVENT DATE (SI MONTH DAY YEAR YEAR LER NUMBER (5)jcg: FEQULNTIAL r@jj REPOR1'ATE (7)DAY YEAR NUMBER"CV~MONTH FACILITY NAMES N/A DOCKET NVMBERIS)0 5 0 0 0 O'THER FACILITIES INVOLVED (5)1 0 2 7 878 7 0 2 6 0 0 1 1 2 4 8 7 N/A 0 5 0 0 0 OPERATINO MODE (SI POWE R LEVEL p p p 20A0215)20AOS(~I (I I (ll 20.405(~Ill l(ii)20AOS (~l(1 I (ill I 20A05 (e I (I)Br)20AOS(~I(ll(rl 20AOS(c)50.35(c)(I I 50.35(cll2) 50.73(el(2)(ll 50.734 I(2)(5)50.734)(2)l Ill)LICENSEE CONTACT FOR THIS LER (12)50.73(e I (2)(lv)50.734)(2 I(r I 50.734)(2)(rB I 50.7341(2)(r)B)(Al 50.73(e)(2)(vlQI(B) 50.73(e)12)(el THIS REPORT IS SUBMITTED PVASVANT 7 0 THE REOUIAEMENTS OF 10 CF R (It ICnrce one or metr of tnr Ioiiowfnfl (11 73.7)(III 73.71(cl OTHER (Specify ln Apettect OelOWrmf ln Tret, NRC FOnn 3FFAI NAME T.R.Bradish, Compliance Lead TELEPHONE NUMBER AREA CODE 602 39 3-353 1 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)CAVSE SYSTEM CO Ml'0 N E NT MANUFAC TVRER REPOR'TABLE TO NPRDS CAUSE SYSTEM COMPONENT MANUFAC.TURER EPORTABLE TO NPRDS R4>M SUPPLEMENTAL AEPOAT EXPECTED (I~I YES (lf yeL complrte El(PECTEO SUBMISSION DATE)NO ABSTRACT ILlmrt to trOO epeceL l.r,.epptoeimetriy Iiltrrn tlnoir epecr typewritten linNI IISI MONTH DAY EXPECTED SUBMISSION DATE (15I YEAR On October 27, 1987 at approximately 0530 NST, Palo Verde Unit 1 was in Mode 6 (REFUELING) when an actuation of the Balance of Plant Engineered Safety Features Actuation System (BOP ESFAS)occurred which was caused by an inadvertent Containment Purge Isolated Actuation Signal (CPIAS).CPIAS also cross tripped a Control Room Essential Filtration Actuation Signal (CREFAS)by design.The ESF actuation occurred when a Radiation Protection Technician did not take sufficient measures to ensure that CPIAS was placed in bypass prior to modifying a conversion factor for radiation monitoring unit RU-37 (Power Access Purge Area).The root cause of this event was a cognitive personnel error in that the technician did not ensur e that CPIAS was placed in bypass as required by pr'ocedural controls.Also, procedural controls did not contain sufficient instructions in a format conducive to operator useability.
SIZE:
To prevent recurrence:
NOTES: Standardized     plant.                                                       05000528 RECIPIENT             CQP    IES          REC IP IENT        CQP IES ID CODE/NAME           LTTR ENCL          ID CODE/NANE        LTTR ENCL PD5 LA                       1      1    PD5 PD                  1    1 LIC ITRA. E                 1       1     DAVIS'                 1     1 INTERNAL: ACRS NICHELSON                 . 1      1    *CRB NOELLER            2    2 AEOD/DOA                     1      1    AEQD/DSP/NAS            1    1 AEOD/DSP/ROAB               2      2    .AEQD/DSP/TPAB          1    1 ARM/DCTS/DAB                 1      1    DEDRO                  1 NRR/DEST/ADB                         0    NRR/DEST/CEB            1    1 NRR/DEBT/ELB.              :1      1    NRR/DEST/ICSB          1    1' NRR/DEBT/NEB                1            NRR/DEST/MTB                  1 NRR/DEST/PSB .               1       1     NRR/DEST/RBB            1    1 NRR/DEBT/SGB                1      1    NRR/DLPG/HFB            1 NRR/DLPG/GAB                1      1    NRR/DOEA/E*B           1    1 NRR/DREP/RAB                1            NRR/DREP/RPB           2    2 NRR/D IS/SIB                1            NRR/PNAS/ILRB           1    1 LE          02      1      1    RES DEPY GI             1    1 Di J            1      1    RES/DE/EIB             1    1 RGN5    FILE      01              1 EXTERNAL:      EQ8cG  QROHi N              5      5    H ST LOBBY WARD               1 LPDR                        1       1     NRC PDR                1     1 NSIC HARRIS'                         1     NSIC MAYSi G            1     1 NOTES:                                     1       1 TOT*L NUNBER OF COPIES REQUIRED: LTTR                 47   ENCL   '6
the responsible individua'1 will be re-instructed as to the importance of ensuring compliance with procedural r equirements training will be conducted to ensure that department personnel are aware of the importance of bypassing radiation monitors prior to changing parameters, and the procedure will be revised.There have been no similar events which followed the sequence of events described herein.711am 8711300193 871124 PDR ADOCK 05000528 8 PDR I I NRC Fore 3SSA I94/3)LICENSEE EVENT REPORT ILER)TEXT CONTINUATION U.S.NUCLEAR REOULATORY COMMISSION APPROVEO OMB NO 3150 0104 EXPIRES: 9/31/88 FACILITY NAME III POCKET NUMSER I2l LER NUMSER IS)YEAR@>SEOVENTrAL srr/M 4 Il rr 4 V rs 10 N rr UM 4 II PAPE ISI Palo Verde Unit 1 TEXT///moro sooco is srl/wrorE rrso sRA/'orro/HRC Fomr 30EA'4/I Ill o s o o o 5 28 87 0 2 6 0 0, 02 oF 0 3 On October 27, 1987 at approximately 0530 HST, Palo Verde Unit 1 was in Mode 6 (REFUELING) with the Reactor Coolant System (RCS)(AB)vented to atmosphere at approximately 80'F when a Containment Purge Isolation Actuation Signal (CPIAS)was initiated on Train"AR of the Balance of Plant Engineered Safety Features Actuation System (BOP ESFAS)(JE).
The CPIAS was initiated by the Channel RAR Power-Access Purge Area Radiation Monitor (RU-37)(IL)(RI).The Train"AR CPIAS then cross-tripped the Train"B" CPIAS, and the Train RAR and RB" Control Room Essential Filtration Actuation Signals (CREFAS)per design.The BOP ESF actuations resulted in the Containment Purge System (VR)being isolated, the Control Room Essential Ventilation System (VI)being actuated and the Essential Chilled Water System (KM)being actuated.Al 1 equipment operated as designed.The BOP ESFAS actuations were identified by control room operators (utility-licensed) as a result of main control board (MCBD)annunciations (ANN).Prior to the ESF actuation, a Radiation Protection (RP)Technician (contractor, non-licensed) had performed a routine setpoint verification during which he identified that RU-37'radiation level conversion factor (RLF), which converts"counts" to units of dose rate, was set at a conservative value such that indicated dose rate would be higher than actual dose rate (1.63E-03 vs.1.60E-03).
The RP Technician then obtained the permission and concurrence of the Assistant Shift Supervisor (utility-licensed) to change the RLF.During the setpoint change, the CPIAS was i nitiated when an erroneous value (1.60E-OO)for the RLF was randomly entered when the monitor'Remote Indication and Control Unit (RIC)(XIK)automatically reset.This self-actuated reset during a process variable change is considered to be abnormal system behavior;however, procedural controls are established to preclude ESF actuations by requiring that the monitor be placed in bypass.Subsequent investigation into the abnormal operation of the RIC could not determine the reason for the RLF being set improperly or the reason that the RIC automatically reset;therefore, an Engineering Evaluation Request has been initiated to evaluate these abnormalities.
Based upon the information prov'ided to the Assistant Shift Supervisor by the RP Technician prior to the RLF conversion, the Assistant Shift Supervisor determined that the alarm/trip was spurious and that there was no actual radiation level increase.The Assistant Shift Supervisor then directed the control room operator (utility-licensed) to reset CPIAS and CREFAS.At 0540 HST the control room operator (utility-licensed) reset CREFAS channels"A" and RB", and CPIAS channels RA" and RB".By 0550 HST, CREFAS actuated Trains"AR and RB" equipment, and CPIAS actuated trains RA" and"BR equipment were returned to normal service.By 0558 HST the Assistant Shift Supervisor had verified that the RLF was set correctly and that all equipment was returned to normal thus terminating the event.The total duration of the event was approximately 28 minutes.NrlC sO/rM 344o I9 93r


NRC For(rr 3SSA (9 83 I.LICENSEE EYENT REPORT ILER)TEXT CONTINUATION U 8 NUCLEAR REOULATORY COMM/SSION APPROVEO OM8 NO 31M QIO(EXPIRES: 8/31/48 FACILITY NAME (II OOCKET NUMSER (1I LER NUM4ER (SI YEAR'jjbr/SSQI/SNTIAL rr VM S rl~p FSyrsloN rr(/rr PACE (3I Pal o Verde Uni t 1 TExT///rrrrrrp s/rore/s tsrRrppr/.
li l
rrw rM/pr'ms/HRc/rorrrr 3/s(A3/(IT(o s o o o 52 88 7 0 2 6 0 0 03oF 0 3 Investigation into the event identified the root cause as being a cognitive personnel error in that the RP Technician (contractor, non-licensed) did not take sufficient measures to ensure that the monitor was placed in bypass..Additionally, the procedural controls were evaluated and determined not to contain sufficient instructions in a format conducive to operator useability.
The applicable procedure, Radiation Monitoring System Operations (75RP-9S(03), contains"Caution" statements in the instructions portions of the procedure which in effect directs the RP Technician to notify the control room prior to making any process variable changes on RU-37.Additionally, 75RP-9Sg03 contains a"Precaution" in the"Job Planning" section which directs the RP Technician to ensure that the control room places BOP ESFAS in bypass prior to making a process variable change in RU-37.Prior to changing the RLF, the RP Technician notified the control r oom in accordance with the"Caution" notes contained in the instructions portion of the procedure; however, he was not aware of the"Precaution" contained in the NJob Planning" part of the procedure.
As corrective action to prevent recurrence:
the responsible individual will be re-instructed as to the importance of ensuring compliance with procedural requirements, training will be conducted to ensure that department personnel are aware of the importance of bypassing radiation monitors which actuate ESF equipment prior to changing parameters which could cause an inadvertent actuation,.
and 75RP-9Sg03 will be revised to provide more definitive guidance'or ensuring that BOP ESFAS is placed in bypass when needed for changing process variables.
The setpoint change was being made in accordance with approved Radiation Protection Department procedures with the exception of the action described above.There were no unusual characteristics of the work location that directly contributed to the event.There were no component, system, or safety train failures that contributed to the event.Therefore, there were no safety consequences or implications of the event.No safety limits were approached, no fission product barriers were challenged, and all equipment functioned as designed.Therefore, there was no threat to the health and safety of the public.There were no structures, systems or components inoperable prior to the event which contributed to the event.There have been other previous events wherein personnel errors have resulted in inadvertent actuations of BOP ESFAS equipment.
However, none of the previous events followed the sequence of events described above nor did any.previous events involve an inadvertent CPIAS actuation due to not following approved procedures.
'cFC r O/IM SSSk (9 83r I (1 t 5 Arizona Nuclear Power Project P.O.BOX 52034~PHOENIX, ARIZONA 85072-2034 192-00313-JGH/TRB/DA J November 24, 1987 NRC Document Control Desk Nuclear Regulatory Commission Washington, D.C.20555.


==Dear Sirs:==
NRC Fotm 355                                                                                                                                              UA. NUCLEAR REOULATORY COMMISSION (9 83)
APPROVED OMB NOr 3150010(
LICENSEE EVENT REPORT ILER)                                                          EXPIRES: SISIISS FACILITY NAME HI                                                                                                                              DOCKET NUMBER (2)                            I'A TITLE Iel Palo Verde Unit                      1                                                                                            05000528>oFp3 Automatic Actuation of                                    an En          ineered Safet                  Feature      Due        to Personnel Error EVENT DATE (SI                        LER NUMBER (5)                                  REPOR1'ATE (7)                          O'THER FACILITIES INVOLVED (5)
MONTH      DAY      YEAR      YEAR    jcg: FEQULNTIAL            r@jj  "CV~
NUMBER MONTH            DAY      YEAR            FACILITYNAMES                          DOCKET NVMBERIS)
N/A                                            0  5    0    0  0 1    0    2 7      878            7            0 2            6          0 0      1      1  2      4 8  7    N/A                                            0  5    0    0  0 THIS REPORT IS SUBMITTED PVASVANT 7 0 THE REOUIAEMENTS OF 10 CF R (It ICnrce one or metr                      of tnr Ioiiowfnfl (11 OPERATINO MODE (SI                    20A0215)                                          20AOS(c)                            50.73(e I (2)(lv)                              73.7)(III POWE R                          20AOS( ~ I (I I (ll                              50.35(c) (I I                      50.734) (2 I(rI                                73.71(cl LEVEL p p      p        20.405( ~ Illl(ii)                                50.35(cll2)                        50.734) (2)(rB I                              OTHER (Specify ln Apettect OelOWrmf ln Tret, NRC FOnn 20AOS ( ~ l(1 I (illI                            50.73(el(2) (ll                    50.7341(2)(r)B) (Al                          3FFAI 20A05 (e I (I) Br)                                50.734  I(2) (5)                    50.73(e) (2)(vlQI(B) 20AOS( ~ I(ll(rl                                  50.734) (2) l Ill)                  50.73(e)12) (el LICENSEE CONTACT FOR THIS LER (12)
NAME                                                                                                                                                                TELEPHONE NUMBER AREA CODE T. R. Bradish,                  Compliance Lead                                                                                        602 39                    3-353                1 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)
Ml'0N E NT        MANUFAC                REPOR'TABLE                                                                    MANUFAC.            EPORTABLE CAVSE    SYSTEM      CO TO NPRDS                                CAUSE SYSTEM  COMPONENT TVRER                                                                                                TURER            TO NPRDS R4>M SUPPLEMENTAL AEPOAT EXPECTED                  (I ~ I                                                                    MONTH    DAY      YEAR EXPECTED SUBMISSION DATE (15I YES  (lf yeL complrte El(PECTEO SUBMISSION DATE)                                              NO ABSTRACT ILlmrt to trOO epeceL l.r,. epptoeimetriy          Iiltrrn tlnoir epecr typewritten linNI IISI On    October 27, 1987                          at approximately 0530 NST, Palo Verde Unit 1 was in                                                              Mode 6 (REFUELING) when an                              actuation of the Balance of Plant Engineered Safety Features Actuation System                                        (BOP ESFAS)                    occurred which was caused by an inadvertent Containment Purge Isolated Actuation Signal (CPIAS). CPIAS also cross tripped a Control Room Essential Filtration Actuation Signal (CREFAS) by design.
The ESF            actuation occurred                              when a            Radiation Protection Technician did not take sufficient              measures                to ensure that                        CPIAS was placed in bypass prior to modifying              a  conversion factor                              for      radiation monitoring unit RU-37 (Power Access Purge Area).
The      root cause of this event was a cognitive personnel error in that the technician did not ensur e that CPIAS was placed in bypass as required by pr'ocedural controls. Also, procedural controls did not contain sufficient instructions in a format conducive to operator useability.
To    prevent recurrence: the responsible individua'1 will be re-instructed as to the importance of ensuring compliance with procedural r equirements training will be conducted to ensure that department personnel are aware of the importance of bypassing radiation monitors prior to changing parameters, and the procedure will be revised.
There have been no                            similar events which followed the                                      sequence              of events described herein.
8711300193 871124                  711am PDR            ADOCK 05000528 8                                          PDR
 
I I
 
NRC  Fore 3SSA I94/3)                                                                                                              U.S. NUCLEAR REOULATORY COMMISSION LICENSEE EVENT REPORT ILER) TEXT CONTINUATION                                APPROVEO OMB NO 3150 0104 EXPIRES: 9/31/88 FACILITY NAME    III                                                    POCKET NUMSER I2l LER NUMSER IS)                          PAPE ISI YEAR @> SEOVENTrAL srr/M 4 Il rr 4 V rs 10 N rr UM 4 II Palo Verde Unit                        1                              o  s  o  o  o  5 28 87        0 2        6          0 0,      02  oF 0 3 TEXT /// moro sooco is srl/wrorE rrso sRA/  'orro/ HRC Fomr 30EA'4/ I Ill On    October 27, 1987                          at approximately 0530 HST, Palo Verde Unit was in Mode 6 1
(REFUELING)                  with the Reactor Coolant System (RCS)(AB) vented to atmosphere at approximately 80'F when a Containment Purge Isolation Actuation Signal (CPIAS) was initiated on Train "AR of the Balance of Plant Engineered Safety Features Actuation System (BOP ESFAS)(JE). The CPIAS was initiated by the Channel RAR Power-Access Purge Area Radiation Monitor (RU-37)( IL)(RI). The Train "AR CPIAS then cross-tripped the Train "B" CPIAS, and the Train RAR and RB" Control Room Essential Filtration Actuation Signals (CREFAS) per design. The BOP ESF actuations resulted in the Containment Purge System (VR) being isolated, the Control Room Essential Ventilation System (VI) being actuated and the Essential Chilled Water System (KM) being actuated.                                      Al equipment 1
operated as designed. The BOP ESFAS actuations were identified by control room operators (utility-licensed) as a result of main control board (MCBD) annunciations (ANN).
Prior to the ESF actuation, a Radiation Protection (RP) Technician (contractor, non-licensed) had performed a routine setpoint verification during which he identified that RU-37' radiation level conversion factor (RLF), which converts "counts" to units of dose rate, was set at a conservative value such that indicated dose rate would be higher than actual dose        rate (1.63E-03 vs. 1.60E-03). The RP Technician then obtained the permission and concurrence of the Assistant Shift Supervisor (utility-licensed) to change the RLF. During the setpoint change, the CPIAS was i nitiated when an erroneous value ( 1.60E-OO) for the RLF was randomly entered when the monitor' Remote Indication and Control Unit (RIC) (XIK) automatically reset. This self-actuated reset during a process variable change is considered to be abnormal system behavior; however, procedural controls are established to preclude ESF actuations by requiring that the monitor be placed in bypass. Subsequent investigation into the abnormal operation of the RIC could not determine the reason for the RLF being set improperly or the reason that the RIC automatically reset; therefore, an Engineering Evaluation Request has been initiated to evaluate these abnormalities.
Based upon                the information prov'ided to the Assistant Shift Supervisor by the RP    Technician prior to the RLF conversion, the Assistant Shift Supervisor determined that the alarm/trip was spurious and that there was no actual radiation level increase. The Assistant Shift Supervisor then directed the control room operator (utility-licensed) to reset CPIAS and CREFAS. At 0540 HST the control room operator (utility-licensed) reset CREFAS channels "A" and RB", and CPIAS channels RA" and RB". By 0550 HST, CREFAS actuated Trains "AR and RB" equipment, and CPIAS actuated trains RA" and "BR equipment were returned to normal service. By 0558 HST the Assistant Shift Supervisor had verified that the RLF was set correctly and that all equipment was returned to normal thus terminating the event. The total duration of the event was approximately 28 minutes.
NrlC sO/rM 344o I9 93r
 
NRC For(rr 3SSA                                                                                                            U 8 NUCLEAR REOULATORY COMM/SSION (9 83 I
                                              . LICENSEE EYENT REPORT ILER) TEXT CONTINUATION                                  APPROVEO OM8 NO 31M QIO(
EXPIRES: 8/31/48 FACILITY NAME (II                                                              OOCKET NUMSER (1I              LER NUM4ER (SI                          PACE (3I YEAR 'jjbr/ SSQI/SNTIAL rr VM S rl
                                                                                                                                ~p  FSyrsloN rr(/rr Pal o Verde Uni                      t  1                                o  s  o  o    o 52 88  7        0 2        6      0 0      03oF          0 3 TExT /// rrrrrrp s/rore /s tsrRrppr/. rrw rM/pr 'ms/ HRc /rorrrr 3/s(A3/ (IT(
Investigation into the event identified the root cause as being a cognitive personnel error in that the RP Technician (contractor, non-licensed) did not take sufficient measures to ensure that the monitor was placed in bypass.
        .Additionally, the procedural controls were evaluated and determined not to contain sufficient instructions in a format conducive to operator useability.
The applicable procedure, Radiation Monitoring System Operations (75RP-9S(03),
contains "Caution" statements in the instructions portions of the procedure which in effect directs the RP Technician to notify the control room prior to making any process variable changes on RU-37. Additionally, 75RP-9Sg03 contains a "Precaution" in the "Job Planning" section which directs the RP Technician to ensure that the control room places BOP ESFAS in bypass prior to making a process variable change in RU-37. Prior to changing the RLF, the RP Technician notified the control r oom in accordance with the "Caution" notes contained in the instructions portion of the procedure; however, he was not aware of the "Precaution" contained in the NJob Planning" part of the procedure.
As corrective action to prevent recurrence: the responsible individual will be re-instructed as to the importance of ensuring compliance with procedural requirements, training will be conducted to ensure that department personnel are aware of the importance of bypassing radiation monitors which actuate ESF equipment prior to changing parameters which could cause an inadvertent actuation,. and 75RP-9Sg03 will be revised to provide more definitive guidance ensuring that BOP ESFAS is placed in bypass when needed for changing                                                        'or process variables.
The setpoint change was being made in accordance with approved Radiation Protection Department procedures with the exception of the action described above. There were no unusual characteristics of the work location that directly contributed to the event. There were no component, system, or safety train failures that contributed to the event. Therefore, there were no safety consequences or implications of the event. No safety limits were approached, no fission product barriers were challenged, and all equipment functioned as designed.                      Therefore, there was no threat to the health and safety of the public. There were no structures, systems or components inoperable prior to the event which contributed to the event.
There have been other previous events wherein personnel errors have resulted in inadvertent actuations of BOP ESFAS equipment. However, none of the previous events followed the sequence of events described above nor did any .
previous events involve an inadvertent CPIAS actuation due to not following approved procedures.
  'cFC r O/IM SSSk (9 83r
 
I
(
1 t
 
5 Arizona Nuclear Power Project P.O. BOX 52034 ~ PHOENIX, ARIZONA85072-2034 192-00313- JGH/TRB/DAJ November 24, 1987 NRC  Document Control Desk Nuclear Regulatory Commission Washington, D.C.        20555
 
==Dear Sirs:==


==Subject:==
==Subject:==
Palo Verde Nuclear Generating Station (PVNGS)Unit 1 Docket No.STN 50-528 Licensee Event Report 87-026-00 F i le: 87-020-404 Attached please find Licensee Event Report (LER)No.87-026-00 prepared and submitted pursuant to 10CFR 50.73.In accordance with 10CFR 50.73(d), we are herewith forwarding a copy of the LER to the Regional Administrator of the Region V office.If you have any questions, please contact T.R.Bradish, Compliance Lead at (602)393-3531.Very truly yours, H~-~J.G.Haynes Vice President~Nuclear Production JGH/TRB/DAJ/kj Attachment cc: 0.M.DeMichele E.E.Van Brunt, Jr.J.B.Martin J.R.Ball R.C.Sorenson E.A.Licitra A.C.Gehr INPO Records Center (al 1 w/a)
Palo Verde Nuclear Generating Station (PVNGS)
Unit   1 Docket No. STN 50-528 Licensee Event Report 87-026-00 F i le:   87-020-404 Attached please find Licensee Event Report (LER) No. 87-026-00 prepared and submitted pursuant to 10CFR 50.73. In accordance with 10CFR 50.73(d), we are herewith forwarding a copy of the LER to the Regional Administrator of the Region   V office.
If you   have any questions, please contact T. R. Bradish, Compliance Lead at (602) 393-3531.
Very truly yours, H~-~
J. G. Haynes Vice President
                                                          ~
Nuclear Production JGH/TRB/DAJ/kj Attachment cc:   0. M. DeMichele           (al w/a) 1 E. E. Van Brunt,       Jr.
J. B. Martin J. R. Ball R. C. Sorenson E. A. Licitra A. C. Gehr INPO Records     Center
 
II 1}}
II 1}}

Latest revision as of 04:32, 4 February 2020

LER 87-026-00:on 871027,automatic Actuation of Balance of Plant ESF Occurred Due to Inadvertent Containment Purge Isolated Actuation Signal.Caused by Personnel Error. Responsible Individual Will Be reinstructed.W/871124 Ltr
ML17303A707
Person / Time
Site: Palo Verde Arizona Public Service icon.png
Issue date: 11/24/1987
From: Bradish T, Haynes J
ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:
NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
192-00313-JGH-T, 192-313-JGH-T, LER-87-026, LER-87-26, NUDOCS 8711300193
Download: ML17303A707 (10)
v • d • e


Text

'EGUL 1

~

. Y INFORNATION DISTRIBUTI SYSTEM (RIDS)

'ACCESSION NBR: 8711300193 DOC. DATE: 87/11/24, NOTARIZED: NO DOCKET ¹ FACIL: BTN-50-528 Palo Verde Nuclear Stations Unit ii Arizona Publi 05000528 AUTH. NANE AUTHOR AFFILIATION I

B R*D SH a T. R . Arizona Nuclear Poeer ProJect (formerly Arizona Public Serv HAYNES'. G. Arizona Nuclear Poeer Pro Ject (formerly Arizona Public Serv REC IP. N*ME RECIPIENT AFFILIATION

SUBJECT:

LER 87-026-00: on 871027'utomatic actuation of balance of plant ESF occurred due to inadvertent containment purge isolated actuation signal. Caused bg personnel error.

Responsible individual mill be reinstructed. W/871124 ltr.

DISTRIBUTION CODE: IE22D COPIES RECEIVED: LTR TITLE: 50. 73 Licensee Event Report (LER)i J ENCL J.

Incident Rpti etc.

SIZE:

NOTES: Standardized plant. 05000528 RECIPIENT CQP IES REC IP IENT CQP IES ID CODE/NAME LTTR ENCL ID CODE/NANE LTTR ENCL PD5 LA 1 1 PD5 PD 1 1 LIC ITRA. E 1 1 DAVIS' 1 1 INTERNAL: ACRS NICHELSON . 1 1 *CRB NOELLER 2 2 AEOD/DOA 1 1 AEQD/DSP/NAS 1 1 AEOD/DSP/ROAB 2 2 .AEQD/DSP/TPAB 1 1 ARM/DCTS/DAB 1 1 DEDRO 1 NRR/DEST/ADB 0 NRR/DEST/CEB 1 1 NRR/DEBT/ELB. :1 1 NRR/DEST/ICSB 1 1' NRR/DEBT/NEB 1 NRR/DEST/MTB 1 NRR/DEST/PSB . 1 1 NRR/DEST/RBB 1 1 NRR/DEBT/SGB 1 1 NRR/DLPG/HFB 1 NRR/DLPG/GAB 1 1 NRR/DOEA/E*B 1 1 NRR/DREP/RAB 1 NRR/DREP/RPB 2 2 NRR/D IS/SIB 1 NRR/PNAS/ILRB 1 1 LE 02 1 1 RES DEPY GI 1 1 Di J 1 1 RES/DE/EIB 1 1 RGN5 FILE 01 1 EXTERNAL: EQ8cG QROHi N 5 5 H ST LOBBY WARD 1 LPDR 1 1 NRC PDR 1 1 NSIC HARRIS' 1 NSIC MAYSi G 1 1 NOTES: 1 1 TOT*L NUNBER OF COPIES REQUIRED: LTTR 47 ENCL '6

li l

NRC Fotm 355 UA. NUCLEAR REOULATORY COMMISSION (9 83)

APPROVED OMB NOr 3150010(

LICENSEE EVENT REPORT ILER) EXPIRES: SISIISS FACILITY NAME HI DOCKET NUMBER (2) I'A TITLE Iel Palo Verde Unit 1 05000528>oFp3 Automatic Actuation of an En ineered Safet Feature Due to Personnel Error EVENT DATE (SI LER NUMBER (5) REPOR1'ATE (7) O'THER FACILITIES INVOLVED (5)

MONTH DAY YEAR YEAR jcg: FEQULNTIAL r@jj "CV~

NUMBER MONTH DAY YEAR FACILITYNAMES DOCKET NVMBERIS)

N/A 0 5 0 0 0 1 0 2 7 878 7 0 2 6 0 0 1 1 2 4 8 7 N/A 0 5 0 0 0 THIS REPORT IS SUBMITTED PVASVANT 7 0 THE REOUIAEMENTS OF 10 CF R (It ICnrce one or metr of tnr Ioiiowfnfl (11 OPERATINO MODE (SI 20A0215) 20AOS(c) 50.73(e I (2)(lv) 73.7)(III POWE R 20AOS( ~ I (I I (ll 50.35(c) (I I 50.734) (2 I(rI 73.71(cl LEVEL p p p 20.405( ~ Illl(ii) 50.35(cll2) 50.734) (2)(rB I OTHER (Specify ln Apettect OelOWrmf ln Tret, NRC FOnn 20AOS ( ~ l(1 I (illI 50.73(el(2) (ll 50.7341(2)(r)B) (Al 3FFAI 20A05 (e I (I) Br) 50.734 I(2) (5) 50.73(e) (2)(vlQI(B) 20AOS( ~ I(ll(rl 50.734) (2) l Ill) 50.73(e)12) (el LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER AREA CODE T. R. Bradish, Compliance Lead 602 39 3-353 1 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

Ml'0N E NT MANUFAC REPOR'TABLE MANUFAC. EPORTABLE CAVSE SYSTEM CO TO NPRDS CAUSE SYSTEM COMPONENT TVRER TURER TO NPRDS R4>M SUPPLEMENTAL AEPOAT EXPECTED (I ~ I MONTH DAY YEAR EXPECTED SUBMISSION DATE (15I YES (lf yeL complrte El(PECTEO SUBMISSION DATE) NO ABSTRACT ILlmrt to trOO epeceL l.r,. epptoeimetriy Iiltrrn tlnoir epecr typewritten linNI IISI On October 27, 1987 at approximately 0530 NST, Palo Verde Unit 1 was in Mode 6 (REFUELING) when an actuation of the Balance of Plant Engineered Safety Features Actuation System (BOP ESFAS) occurred which was caused by an inadvertent Containment Purge Isolated Actuation Signal (CPIAS). CPIAS also cross tripped a Control Room Essential Filtration Actuation Signal (CREFAS) by design.

The ESF actuation occurred when a Radiation Protection Technician did not take sufficient measures to ensure that CPIAS was placed in bypass prior to modifying a conversion factor for radiation monitoring unit RU-37 (Power Access Purge Area).

The root cause of this event was a cognitive personnel error in that the technician did not ensur e that CPIAS was placed in bypass as required by pr'ocedural controls. Also, procedural controls did not contain sufficient instructions in a format conducive to operator useability.

To prevent recurrence: the responsible individua'1 will be re-instructed as to the importance of ensuring compliance with procedural r equirements training will be conducted to ensure that department personnel are aware of the importance of bypassing radiation monitors prior to changing parameters, and the procedure will be revised.

There have been no similar events which followed the sequence of events described herein.

8711300193 871124 711am PDR ADOCK 05000528 8 PDR

I I

NRC Fore 3SSA I94/3) U.S. NUCLEAR REOULATORY COMMISSION LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVEO OMB NO 3150 0104 EXPIRES: 9/31/88 FACILITY NAME III POCKET NUMSER I2l LER NUMSER IS) PAPE ISI YEAR @> SEOVENTrAL srr/M 4 Il rr 4 V rs 10 N rr UM 4 II Palo Verde Unit 1 o s o o o 5 28 87 0 2 6 0 0, 02 oF 0 3 TEXT /// moro sooco is srl/wrorE rrso sRA/ 'orro/ HRC Fomr 30EA'4/ I Ill On October 27, 1987 at approximately 0530 HST, Palo Verde Unit was in Mode 6 1

(REFUELING) with the Reactor Coolant System (RCS)(AB) vented to atmosphere at approximately 80'F when a Containment Purge Isolation Actuation Signal (CPIAS) was initiated on Train "AR of the Balance of Plant Engineered Safety Features Actuation System (BOP ESFAS)(JE). The CPIAS was initiated by the Channel RAR Power-Access Purge Area Radiation Monitor (RU-37)( IL)(RI). The Train "AR CPIAS then cross-tripped the Train "B" CPIAS, and the Train RAR and RB" Control Room Essential Filtration Actuation Signals (CREFAS) per design. The BOP ESF actuations resulted in the Containment Purge System (VR) being isolated, the Control Room Essential Ventilation System (VI) being actuated and the Essential Chilled Water System (KM) being actuated. Al equipment 1

operated as designed. The BOP ESFAS actuations were identified by control room operators (utility-licensed) as a result of main control board (MCBD) annunciations (ANN).

Prior to the ESF actuation, a Radiation Protection (RP) Technician (contractor, non-licensed) had performed a routine setpoint verification during which he identified that RU-37' radiation level conversion factor (RLF), which converts "counts" to units of dose rate, was set at a conservative value such that indicated dose rate would be higher than actual dose rate (1.63E-03 vs. 1.60E-03). The RP Technician then obtained the permission and concurrence of the Assistant Shift Supervisor (utility-licensed) to change the RLF. During the setpoint change, the CPIAS was i nitiated when an erroneous value ( 1.60E-OO) for the RLF was randomly entered when the monitor' Remote Indication and Control Unit (RIC) (XIK) automatically reset. This self-actuated reset during a process variable change is considered to be abnormal system behavior; however, procedural controls are established to preclude ESF actuations by requiring that the monitor be placed in bypass. Subsequent investigation into the abnormal operation of the RIC could not determine the reason for the RLF being set improperly or the reason that the RIC automatically reset; therefore, an Engineering Evaluation Request has been initiated to evaluate these abnormalities.

Based upon the information prov'ided to the Assistant Shift Supervisor by the RP Technician prior to the RLF conversion, the Assistant Shift Supervisor determined that the alarm/trip was spurious and that there was no actual radiation level increase. The Assistant Shift Supervisor then directed the control room operator (utility-licensed) to reset CPIAS and CREFAS. At 0540 HST the control room operator (utility-licensed) reset CREFAS channels "A" and RB", and CPIAS channels RA" and RB". By 0550 HST, CREFAS actuated Trains "AR and RB" equipment, and CPIAS actuated trains RA" and "BR equipment were returned to normal service. By 0558 HST the Assistant Shift Supervisor had verified that the RLF was set correctly and that all equipment was returned to normal thus terminating the event. The total duration of the event was approximately 28 minutes.

NrlC sO/rM 344o I9 93r

NRC For(rr 3SSA U 8 NUCLEAR REOULATORY COMM/SSION (9 83 I

. LICENSEE EYENT REPORT ILER) TEXT CONTINUATION APPROVEO OM8 NO 31M QIO(

EXPIRES: 8/31/48 FACILITY NAME (II OOCKET NUMSER (1I LER NUM4ER (SI PACE (3I YEAR 'jjbr/ SSQI/SNTIAL rr VM S rl

~p FSyrsloN rr(/rr Pal o Verde Uni t 1 o s o o o 52 88 7 0 2 6 0 0 03oF 0 3 TExT /// rrrrrrp s/rore /s tsrRrppr/. rrw rM/pr 'ms/ HRc /rorrrr 3/s(A3/ (IT(

Investigation into the event identified the root cause as being a cognitive personnel error in that the RP Technician (contractor, non-licensed) did not take sufficient measures to ensure that the monitor was placed in bypass.

.Additionally, the procedural controls were evaluated and determined not to contain sufficient instructions in a format conducive to operator useability.

The applicable procedure, Radiation Monitoring System Operations (75RP-9S(03),

contains "Caution" statements in the instructions portions of the procedure which in effect directs the RP Technician to notify the control room prior to making any process variable changes on RU-37. Additionally, 75RP-9Sg03 contains a "Precaution" in the "Job Planning" section which directs the RP Technician to ensure that the control room places BOP ESFAS in bypass prior to making a process variable change in RU-37. Prior to changing the RLF, the RP Technician notified the control r oom in accordance with the "Caution" notes contained in the instructions portion of the procedure; however, he was not aware of the "Precaution" contained in the NJob Planning" part of the procedure.

As corrective action to prevent recurrence: the responsible individual will be re-instructed as to the importance of ensuring compliance with procedural requirements, training will be conducted to ensure that department personnel are aware of the importance of bypassing radiation monitors which actuate ESF equipment prior to changing parameters which could cause an inadvertent actuation,. and 75RP-9Sg03 will be revised to provide more definitive guidance ensuring that BOP ESFAS is placed in bypass when needed for changing 'or process variables.

The setpoint change was being made in accordance with approved Radiation Protection Department procedures with the exception of the action described above. There were no unusual characteristics of the work location that directly contributed to the event. There were no component, system, or safety train failures that contributed to the event. Therefore, there were no safety consequences or implications of the event. No safety limits were approached, no fission product barriers were challenged, and all equipment functioned as designed. Therefore, there was no threat to the health and safety of the public. There were no structures, systems or components inoperable prior to the event which contributed to the event.

There have been other previous events wherein personnel errors have resulted in inadvertent actuations of BOP ESFAS equipment. However, none of the previous events followed the sequence of events described above nor did any .

previous events involve an inadvertent CPIAS actuation due to not following approved procedures.

'cFC r O/IM SSSk (9 83r

I

(

1 t

5 Arizona Nuclear Power Project P.O. BOX 52034 ~ PHOENIX, ARIZONA85072-2034 192-00313- JGH/TRB/DAJ November 24, 1987 NRC Document Control Desk Nuclear Regulatory Commission Washington, D.C. 20555

Dear Sirs:

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Unit 1 Docket No. STN 50-528 Licensee Event Report 87-026-00 F i le: 87-020-404 Attached please find Licensee Event Report (LER) No. 87-026-00 prepared and submitted pursuant to 10CFR 50.73. In accordance with 10CFR 50.73(d), we are herewith forwarding a copy of the LER to the Regional Administrator of the Region V office.

If you have any questions, please contact T. R. Bradish, Compliance Lead at (602) 393-3531.

Very truly yours, H~-~

J. G. Haynes Vice President

~

Nuclear Production JGH/TRB/DAJ/kj Attachment cc: 0. M. DeMichele (al w/a) 1 E. E. Van Brunt, Jr.

J. B. Martin J. R. Ball R. C. Sorenson E. A. Licitra A. C. Gehr INPO Records Center

II 1

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