ML19332E626

LER 89-015-00:on 891020,sample Canisters for Auxiliary Bldg Vent Stack Radiation Monitor Removed & Not Analyzed within 48 H.Caused by Programmatic Deficiencies & Personnel Error. Procedures & Training Programs revised.W/891204 Ltr

ML19332E626
Person / Time
Site:	Braidwood
Issue date:	12/02/1989
From:	Querio R, Roche E COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
BW-89-3119, LER-89-015-04, LER-89-15-4, NUDOCS 8912080105
Download: ML19332E626 (6)

Text

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.L' s Conunempechh Edison '

'I - . ' Breldwood Nutlear Power Station -

i* Moute C1, Box 84

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Brecoville, Illinob 00407 j ,' s Telephone 815/468-2001 ~  ;

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December 4,1989 -

BW/89-3119 I>

1. 10 U. S. Nuclear Regulatory Commission j Document Control Desk i Washington, D.C. 20555

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Dear Sir:

. The enclosed Licensee Event Report from Braldwood Generating l Station is being transmitted to you in accordance with the requirements of  :

10CFR50.73(aX2XI) which requires a 30-day written report.

This report is number 89-015-00; Docket No. 50-456. l t

Very truly yours, l

<,4

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. . E. Querto

. . Station Manager 1 Braidwood Nuclear Station .

REQ /JDW/jfe j t (7126z)

Enclosure:

Licensee Event Report No. 89-015-00 -,

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l cc: . NRC RegionIll Administrator NRC Resident Inspector INPO Record Center CECO Distribution List *

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. 1 LICENSEE EVENT REPORT (LER) j

, rm M R facilit-y Name '(1) Docket Number (2) . Pane (3)  ;

ita W sad unit 1 el si el el el di si s 1 l efl e l s  !

fitle (4) Missed Isotopic Analysis for Particulate $ ample Cartridge as a Result of Programmatic Deficiencies )

and Personnel Error Ewent hate f5) LER " r (s) -

Regert Date (7) Other Facilities Involved (8)

Year Year /// Sequential /// Revision Month Day Year Faelitiv 's _Dotket E mberia)

[ Month Day fff fff

/// haber /// haber

. Hone _pl si el el_el l I il a 21 e el e _ s1. 9 ei1Is ei e 1l2 el 2 al 9 el si el el el 1 1 THIS REPORT !$ $UBMITTED PUR$UANT TO THE REQUIREMENTS Of 10CFR I (Check one er more of the followinn) (II)

• 20.402(b) _, 20.40$(c)- _ 50.D(a)(2)(iv) _ 73.71(b)

PONER __ 20.40$(a)(1)(1) __ 50.36(c)(1) _ 501r3(a)(2)(v) _ 73.71(c) j LEVEL 20.405(a)(1)(li) ___ 50.36(c)(2) 50.73(a)(2)(vil) _ Other ($pecify 4 e! o! o (10) __ 20.40$(a)(1)(iii) _]L 50.73(a)(2)(1) 50.73(a)(2)(viii)(A) in Abstract  !

_ 20.40$(a)(1)(iv) .__ 50.73(a)(2)(ii) _ 50.73(a)(2)(viii)(B) below and in

, _ 20.405(a)(1)(v) ._._ 50.73(s)(2)(lii) _ 50.73(a)(2)(x) Text) ,

LICENSEE CONTACT FOR TH15 LER (12)

Name T ELLEHQHL_Bl!RER AREA CODE E. anthe. Health Physics Ext. 2135 8l1Is el El Bl l 2181 el COnetETE ONE LINT FOR EACH COMPONEN FAILURE DLiC11 RED IN TH11 REPORT (13)

CAU$E SYSTEM COMPONENT MANUFAC- REPORTABLE CAUSE $Y$1EM COMPONENT MANUFAC. REPORTABLE TURER TO NPRDS- TURER 70 NPRDS I i i 1 1 I I N I l l I I I I ,

1 I I I I I I I I I I I I i SUPPLEMENTAL REPORT EXPECTED (14) Expected Month.]_ day _LYtar .

Subelssion lYes (if ves. comoltle EXPECTED _.$Upfil}$10N DATE)

X l NO l l l ABSTRACT (Limit to 1400 spaces, i.e. approximately fif teen single-space typewritten lines) (16) i At 0835 on October 20, 1989, the sample canisters for Unit i Auxiliary Building Vent Stack Radiation Monitor IPR 028J. were removed and were required to be analyzed within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br />. While entering date on the Counting Room Sample Log, the Cheelstry Technician (CT) made an erroneous entry in the space for the Isotopic Analysis (Ir the Particulate Sample Cartridge. Later that day, a Health Physics Supervisor (HPS) reviewed the results. At 0635 on October 22, 1989, the Sample Analysis Time Limit was exceeded. On November 2 a dif f rent HPS, who processes the 00CM calculations, requested a printout of the analysis. It was discovered that the analysis had not been performed. An analysis was then performed, no activity was indicated. The root cause of this event was that the existing sampilhg program did not verify the Technical Specification sampling requirements and their associated time limits. A contributory cause was a failure of the CT to

.perfsrm the analysis as a result of the erroneous log entry. The Radiation Protection and Chemistry Department procedures and training programs will be revised as necessary to address this event. There have be:n previous occurrences of missed sampling requirements due to progransnatic deficiencies. The previous c:rr:ctive actions addressed root and contributing causes and are not applicable.

2939m(120289)/2

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Year /// Sequential /// Revision fff fff

/// MWr /// MWr c

arm e " unit i eIsieIeie141 sis ale . eIiIs - eIe el 2 or el s TEXT .' . Energy Industry Ider.lification System (E!!$) codes are identified in the text as (KK) b .

P C. PLANT CONDITIONS PRIOR TO EVENT:

-Unit: Draidwood I; Event Date: October 22, 1989;' Event time: 0836; Mode: N . Defueledi- Rx Power: 0%;

-.RCS (AB) Te'mparature/ Pressure: Ambient /Ateesphe're

9.- DESCRIPfl0N OF EVEN1;

.There were no systems or components inoperable at the beginning of the event which contributed to the severity of the event.

During the day shif t on October 20, 1989, the sample canisters for Unit 1 Aux 111ery Building Vent Stack Radiation Moalter (PR) (IL).1PR028J. were removed from the monitor by a Radiation Protection Technician (RPT).

(Non-Licensed Health Physics personnel). There were three sample canisters. One for tritium, one for lodine and one for Particulate. The Particulate cartridge required an Isotopic Analysis and a 6 hour6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> gross Alpha count.

Braidwood Technical Specification Table 4.11-2 specifies that the sample canisters be changed at least once per 7 days and analysis perfomed within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> of sample canister removal. The sample canisters were labeled by the RPT. The label specified the types of analysis to be performed, when the sample canister had been removed, and where it had been removed from. . _ . .

L f At 0835 the RPT took the sample canisters to the Chemistry Lab for sample analysis. The samples were entered into

.the ' Counting Room $ ample Log", SWAP 550-22TI. The log was a tracking device for items that were brought to the f[

i' Chemistry tab for sample analysis. The log provided for identification and completion signof f for the activities associated with an item.

Lat:r that' day, a Chemistry Technician (CT) (Non-Licensed Chemistry Personnel) was performing the analysis of the

!- , samples on the counting room sample log. During the entering of data on the Counting Room Sample Log the CT inadvertently entered the $pectrum Flie # for the Isotopic Analysis perfomed on the lodine Sample cartridge in the space for the Isotopic Analysis for the Particulate Sample Cartridge. The CT lined out the entry and er.tered the data for a 6 Hour Gross Alpha Analysis above the line out. The CT entered the lodine $ ample data in the  ;

csrr:ct. space. ~The CT then continued with other activities without performing the specified Isotoolc Analysis on the Particulate Sample Cartridge.

l

~ Later that day, a Health Physics Supervisor (HPS) (Non-Licensed Supervisor) reviewed the results of the various samples that had been collected by RP and analyzed by Chemistry. The HP$ signed for receiving the sample results cf the analysis that had been completed. The HPS did not observe that the Particulate Isotopic Analysis had not been performed. The HPS forwarded the analysis sheets to a dif ferent HP$ who is designated as the responsible L person.for tracking sample analysis results as inputs into the ODCH calculations.

At 0835, on October 22, 1989, the Sample Analysis Time Limit was exceeded.

.On the' evening of November 1, 1989, the second HPS was assembling data for ODCM calculations. He noted that he did not have a copy of the printout for the sample results for the partievlate isotopic analysis of the 1PR028J sample. canisters.

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3 J LICENstt EVENT REPotf fttti TEXT CONTitanTION Form Rev 2.e FACILITY IIME (1) DOCKET lO SER (2) . . LER NLDRER (6) _

Pane 01 Year // Sequential //j/ Revision l //j/j f

/ Number ff

/// Number =

ara h ad unit i eIsIeieIo141 sis a1e - ei1Is - eie el 3 or el s p.

TEXT Energy Industry Identifitation System (E!!$) codes are identified in the text as (XX)

- 9. DESCRIPTI M 0F EVENT. CONilNVED:

On November 2, 1989, the second HP$ requested a printout of the particulate isotopic analysis from the Chemistry Supervisor. The Chemistry $upervisor discovered that the sample had not been analyzed. The

- particulate sample was analyzed to determine if any particulate could be quantified. The results indicated that no particulates could be quantified.

Based on the initial information associated with this event, a 'Braidwood Station Error Evaluation Presentation" was held to review this event with the personnel directly involved and their supervisors. The l- c:rrective actions addressing both root and contributing causes are detailed below.

i This event is being reported pursuant to 10CFR50.73(a)(2)(1) - any operation or condition prohibited by the Pl ants Technical $pecifications.

l C. CAU$t 0F EVENT:

The root cause of this event was a prograsunatic deficiency. The existing Sampling Analysis program did st provide positive verification of Technical Specification sampilng requirements and their associated time

'r:quirements.

A contributory cause was a f ailure of the Chemistry Technician to perform the isotopic analysis on the Particulate Sample Cartridge.

1 D.- $AFETY ANALYSI$:

This event had no affect on the safety of the plant or the public. Radiation monitor IPR 028J. and the

'Aualliery Building Wide Range Gas Monitor were operable throughout the event, f Under worst case accident conditions these monitors would have been available to monitor Auxiliary Butiding v:ntilation Stack Effluent Activity.  ;

E. CORRECTIVE ACTIONS:

I l- The Particulate $ ample Cartridge was lasnediately analysed. The results indicated that no particulates could be quantified.

Based on the initial information associated with this event, the personnel directly involved with this event participated in a "Braidwood Station Error Evaluation Presentation" to identify the root and contributing causes of this event. Based on the conclusions of this presentation the following corrective actions will be taken:

Prccedure BwRP 1280-919. Vent Stack Particulate filter Iodine Cartridge Sample Data $heet, will be revised to

. include a signature slot for the RPT collecting the samples. This will ensure that all information required for perforcing ODCH calculations is documented at the time the samples are collected. This will be tracked to completion by action item no. 456-200-89-18301.

2939m(120489)/4

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~, y L1rrentf EVENT REPORT f Ltti TERI CONT! Milk. f em ter 2.s

' FACILITY M48E (1) DOCKET NLDSER (2) LER NLDRER (6) pane (3) ,,,,_

Year /// Sequential /// Revision ff fff

/// haker tit' ___naktt-araidmand unu 1 e 1 5 i e I e 1 e 1 41 51 6 a1e - e I 1J 5 - eie el 4 or el s ,

TEXT Energy Industry Identification System (Ell $) codes are identified in the text as [KK) i l

E.1 CORRECTIVE ACTIONS CONTINVED:

L A checklist will be developed to control processing of Technical $pecification samples from initial sampling i through co11ection of the results. The specific instructions in this checklist will include signature r:guirements for each step to ensure accountability of results. This will be tracked to completion by action item no. .456-200-89-18302.

'A tailgate session reviewing the details of this event will be held with each of the departments. This will.  ;

be tracked to completion by action ites no. 456-200-89-18303.

A specifically labeled bin will be prepared for Technical $pecification samples and will be located in the  :

Chemistry Counting Room. This will. ensure these sempies do not get aisplaced or assigned a lower priority.

This will be tracked to completion by action item no. 456-200-89-180304.

i Training. on the new program requirements, will be provided to both the Radiation Protection Department and the Cheelstry Department. This will be tracked to completion by action itse no. 456-200-89-18305. l The' training programs for the Radiation protection Technician and Chemistry Technician requalification and ,

continuous training will be evaluated. Revisions will be made as necessary. This will be tracked to i completion by action item no. 456-200 89-18306.

A fgroal Duty HP training program will be developed. This will be tracked to completion by action item no. I 456-200-89-18307. l F. PREVIOU$ OCCURRENCES:

Thero have been previous occurrences of missed choeistry sampling requirements due to programmatic deficiencies.

The previous steller occurrences are as follows: i DVR / LER TITLE DVR 20-1 87-273/ Missed Reactor Coolant $pecific Activity LER 87-043 Sample Due to Hisconnunications

'The root cause of this event was a misconnunication between a licensed operator and a non-licensed chemist.

DVR 20-1-87-316/ Exceeded Analysis Frequency on Waste LER 87-049 Gas Oxygen Analysis This event.was a-result of a programmatic deficiency. The method for tracking and completing samples was verbal and the method f or assigning and trac 61ng completion of samples was not formalized.

2939m(120489)/5-

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• Llerutrr tyralt atput (tra) itXT enuttaggT10hl Fern key L A FAClttfV 0140E (1) 00CKti spett (2) Ltt tasett (6) Pane (3) I Year /// Sequential /// Revisten f fff fff

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c. l h .Arataand unit 1 0IsIeieIe141 sis aIe - ei1Is - eIe el s or el s j TEKf Energy Industry !dentificatten $ystem (E!!$) codes are identified in the text as (KK) i 4

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(F.-PRtV100$DCCURRENCC$[ CONTINUED:

i h .. DWR 20-1-48-145/ .Lest CesposIte $amples Due io- )

LCR 88-013 programmatic Deficiency  ;

.There were no spectfic provisions for disposition of the composite samples which caused the samples to be j staplaced and/or discarded after they had been analyzed.

DVR 20-1-86-171/ Missed Technical.$pectfication Composite ,

Ltt 06-017 Samples Due to failure to Implement Required Changes j

- . i i

l- < this event was the result of f ailure of Chemistry personnel to interpret the Technical Specification matrix

(- changes regarding chemistry composite samp1tng requirements. i

.i i

The corrective actions were. implemented addressing both root' and contributing causes. previous corrective  ;

I actions are not applicable'to this event.

i --' 4.' CONPONENT IAlLURE DATA:

1:

L This event was not the result of component failure, nor did any components fall as a result of this event. ,

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2939m(120289)/6- ,

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