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{{#Wiki_filter:1!ndianaMichiganPowerCompanyCookNuc!earP!ant".neCookPlaceBridgman.Ml~91066164655901May20,1992diagINDIANJLNlCHlG4NPOWERUnitedStatesNuclearRegulatoryCommissionDocumentControlDeskRockville,Maryland20852OperatingLicensesDPR-58DocketNo.50-315DocumentControlManager:lnaccordancewiththecriteriaestablishedby10CFR50.73entitledLicenseeEventReortSstemthefollowingreportisbeingsubmitted:92-004-00Sincerely,A.A.BlindPlantManager/sbAttachmentcD.H.Williams,Jr.tA.B..Davis.,Region~?Q'.E.FitzpatrickP.A.BarrettB.F.Henderson,R.F.KroegerB.Walters-Ft.WayneNRCResidentInspectorJ.F.Stang-NRCJ.G.KepplerM.R.PadgettG.Charnoff,Escr.D.HahnXNPOS.J.Brewer/B.P.LauzauB.A.SvenssonQ'cOygagANg61SR NRCFORM366(649)FACILITYNAMElllVS.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)D.C.CookNuclearPlant-Unit1APPROVED0MBNO.3150410CEXPIRES:C/30I92ESTIMATEDBURDENPERRESPONSETOCOLIPLYWTHTHISINFORMATIONCOLLECTIONREOUEST.500HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMFNTBRANCH(F630),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON.DC20555,ANDTOTHEPAPERWORKREDUCTIONPROJECT(31$0C)10el.OFFICEOFMANAGEMENTANDBUDGET,WASHINGTON.DC20503.DOCKETNUMBER(2)PAE3050003151OF04TITLEIclEVENTOATK(5)MissedSurveillanceonBoricAcidFlowPathduetoPersonnelErrorDuringProcedureReviewProcessREPORTDATE(7)OTHERFACILITIESINVOLVED(4)LERNUMBERLSIMONTHOAYYEARYEARSEOVENTIALNVMSEIINVMSEIIREVOKEMON)'HOAYYEARFACILITYNAMESDOCKETNUMBFR(SI05000042092920040005209205000OPERATINGMODE(4)POWERLEYEL,899cR~'ro"'CV)O;r.carr.@20A02(SI20A05(e)()Ill)20A054)(1l(EI20AOS(e)(I)(IIII20A054)(1)tlrl20.4054)(1I(rl20AOS(cl50M(el)1)50.34(c)(2)50.73(e)(2)lll60734)l2)(9)50.73Iel(2)(lli)LICENSEECONTACTFORTHISLER(12)50.73(el(2IGrl60.73(el(2)(rI50.734l(2Hrii)60.73(e)12)(rill)IAl50.734I(2I4lil)I5I50,7S(~)IS)(el0THERSOU(AEMENTSOF10CFR():IC>rrCCOnrOrmrrrOftnrfOIIOwinpl(11THISREPORTISSUBMITTEDPURSUANTT73.71(SI73.7((c)OTHERISorc>fy>nAottrrctOelowrnrfInFret,HACFormSSSA>NAMEJ.R.Sampson,OperationsDepartmentTELEPHONENUMBERAREACODE616465-5901COMPLETEON!LINEFOREACHCOIAPONENTFAILUREDESCRIBEDIHTHISREPORTIIS)CAUSESYSTEMCOMPONENTMANUFAC.TUAERFPOATABLF.TONPAOSCAUSESYSTEM~~Xo..r;rlCOMPONENTMANUFAC.TUREAEPOATABLTONPAOSk~mc@o~5SUPPLEMENTALREPORTEXPECTEDIICIYESllfyrt,compirtrEXPECPEI>SVSMISSIONDATEINOABSTRACTl(,lmittotc00torcrLIr.,rpproelmrtrlylilrrrntinplrtprtrtyPrwnttrnlinwll14)EXPECTEDSUBMISSIONDATE(15)MONTHDAYYEAROn4-20-92,contrarytoTechnicalSpecification(TS)4.1.2.2.a.l,theseven-daytesttoprovetheoperabilityoftheborationflowpathsfromtherefuelingwaterstoragetankandtheboricacidstoragetankwasnotperformedasscheduled.Thetestisaccomplishedbycyclingeachtestablepower-operatedorautomaticvalveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillancewasidentifiedon4-24-92.Thesurveillanceprocedurewasimmediatelyperformed.Alltestacceptancecriteriaweremet.Themissedsurveillanceoccurredasaresultofpersonnelerrorduringthereviewprocess.Thefindingsofthiseventwerereviewedwiththeinvolvedpersonnelbytheirsupervisors.NRCForm344(649)
{{#Wiki_filter:1!ndianaMichiganPowerCompanyCookNuc!earP!ant".neCookPlaceBridgman.
NRCFORM3rrSA(689)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVEREPORT(LERITEXTCONTINUATIONtAPPROVEDOMBNOr31504104EXPIRES:rU30/92ESTIMATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:500HRS.FORWARDCOMMENTSRFGARDINGBURDENESTIMATETOTHERECORDSANOREPORTSMANAGEMENTBRANCH(P430).U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,OC20555,ANOTO1NEPAPERWORKREDUCTIONPROJECT(3)500104),OFFICEOFMANAGEMENTANOBUDGET,WASHINGTON.DC20503.FACILITYNAME(1)DOCKETNUMBKR(2)LERNUMBER(SlPAGE(3)YEARIISKDUKNTIAL;~NUMSSRREVISIONNVMISIID.C.CookNuclearPlant-Unit1TEXT(Ifmorespeceisrer)rrirer(IreeaAiiriorreiiVRCFormJSSAK)(IT)31592004-0002OF04ConditionsPriortoOccurrenceUnitone(U-1)inmodeoneat89.9Xpower.Unittwo(U-2)inmodesixatOXpower.DescritionofEventOn4-20-92,the1-OHP4030.STP.002V(BorationSystemValvePositionVerificationandTesting)surveillanceprocedurewasnotperformedtosatisfytheTechnicalSpecification(TS)surveillancerequirement4.1.2.2.a.lforTS3.1.2.2(ReactivityControlSystemsFlowPaths-Operation).TS4.1.2.2.a.lrequiresatleastoncepersevendaysthattheborationflowpathsfromtherefuelingwaterstoragetank(RWST)(EIIS/CB-TK)andtheboricacidstoragetank(BAST)(EIIS/CB-TK)beprovenoperablebycyclingeachtestablepower-operatedorautomaticvalveintheflowpaththroughatleastonecompletecycleoffulltravel.ThemissedsurveillanceprocedurewasdiscoveredbyanOperationsDepartmentEngineeron4-24-92,Thesurveillancetestwaslastperformedon4-13-92.TheTSactionstatementwasenteredat1255hoursandthe1-OHP4030.STP.002Vsurveillanceprocedurewasstarted,completed,andreviewedby1314hourson4-24-92.Areviewofthecompletedsurveillancenotedthatthesurveillanceacceptancecriteriaweresatisfiedandtheactionstatementwasexitedatthistime.On4-20-92,theinvolvedUnitSupervisor(SeniorReactorOperator)reviewedthe1-OHP4030.STP.002Vpaperworkcompletedduringhisshift.Followingthisreview,theUnitSupervisorrecordedthecompletedsectionsofthe1-OHP4030.STP.002VsurveillanceprocedureintheMasterSurveillanceSchedule.Whilerecordingthecompletedsectionsofthesurveillanceprocedurejustreviewed,theUnitSupervisorincorrectlyrecalledthattheweeklysurveillancesectionoftheprocedurehadbeencompletedandsignedofftheweeklysurveillanceprocedureascomplete.Followingtheperformanceofthesurveillanceslistedontheschedule,theOperationsDepartmentEngineeringSectionconductsareviewofthecompletedsurveillancepaperwork.Duringthissurveillancepaperworkreview,theengineersidentifiedon4-21-92thatthe1-OHP4030.STP.002Vweeklysurveillanceproceduresheetsweremissing.UpondiscoveringthatNRCForm36SA(689)  
Ml~91066164655901May20,1992diagINDIANJLNlCHlG4NPOWERUnitedStatesNuclearRegulatory Commission DocumentControlDeskRockville, Maryland20852Operating LicensesDPR-58DocketNo.50-315DocumentControlManager:lnaccordance withthecriteriaestablished by10CFR50.73entitledLicenseeEventReortSstemthefollowing reportisbeingsubmitted:
)ACFORM3nSA(64)9)U.S.NUC(.EARREGULATORYCOMMISSIONLICENSEEEVEREPORT(LER)TEXTCONTINUATIONAPPROVEQ0MBNO.31500104EXPIRES:4/30/92ESATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREOUESTI500HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENTBRANCH(PJ)301.U.S.NUCLEARREGULATORYCOMMISSION.WASHINGTON,DC20555,ANDTO1'HEPAPERWORKREDUCTIONPROJECT(3(500(041,OFFICEOFMANAGEMENTANDBUDGET,WASHINGTON.DC20503..FACILITYNAME(1)DOCKETNUMBER(2)LERNUMBER(6)YEAR'julSEQUENTIAL,g>I(gREVISIONNUMBSR'..:MUAISSRPAGE(3ID.C.CookNuclearPlant-Unit1TEXT///moreepeoeLsJe)rrie(Loee~NRCForrlr36SA'4)l)7)31592-004-00P30Fptheweeklysurveillanceproceduresheetsweremissing,theengineersdocumentedthattheweeklysurveillanceprocedurewasingracebyrecordingthestatusinthegracesectionoftheSurveillanceStatusSummaryReport.Althoughtheengineersidentifiedthattheweeklysurveillancewasapparentlyingraceduetothemissingpaperwork,theengineersdidnotpursuefurtherwhythesurveillanceprocedurehadnotbeencompleted.Thiswasbasedontheengineers'astexperiencehadshownthatthecontrolroomoperatorsalsotrackincompletesurveillancesandpursuethecompletionofasurveillancebeforethegraceperiodexpires.CauseofEventThecauseforthemissedsurveillancewaspersonnelerror.TheUnitSupervisordevelopedamindsetduringthesurveillancereviewthatthesurveillancewascompletedandthereforesignedoffthesurveillanceprocedureascompleteontheschedule.Inaddition,theengineershadamindsetthatcontrolroomoperatorsrecordandtracksurveillancesingraceandthatthecontrolroomoperatorswereawarethatthesurveillancehadnotbeencompleted,orthatthepaperworkmusthavebeenroutedtotheengineersandhadnotarrived.Therefore,theengineersdidnotpursuefurtherthecompletionofthesurveillance.A~nalslsTechnicalSpecification(TS)4.1.2.2.a.l(ReactivityControlSystemsFlowPaths-Operating)requiresatleastoncepersevendaystheborationflowpathsfromtherefuelingwaterstoragetank(RWST)andtheboricacidstoragetank(BAST)tobeprovenoperablebycyclingeachtestablepower-operatedorautomaticvalveintheflowpaththroughatleaseonecompletecycleoffulltravel.ThefailuretoperformthesurveillanceisaviolationofTechnicalSpecification3.1.2.2andisreportableunder10CFR50.73(a)(2)(i)(B).Followingtheidentificationofthemissedsurveillance,the1-OHP4030.STP.002VsurveillanceprocedurewasperformedtosatisfytherequirementsofTS4.1.2.2.a.l.Areviewofthecompletedsurveillancenotedthattherequirementsofthesurveillanceprocedureweremet.Therefore,itisconcludedthatthevalvestestedbythesurveillanceprocedurewouldhaveperformedtheirsafetyfunctionifrequiredduringthetimeperiodfromthelastcompletedsurveillanceprocedureon4-13-92andthesurveillanceprocedureperformedon4-24-92.NR0Form366A(6419)
92-004-00 Sincerely, A.A.BlindPlantManager/sbAttachment cD.H.Williams, Jr.tA.B..Davis.,Region~?Q'.E.Fitzpatrick P.A.BarrettB.F.Henderson
I/RCFOR)4A(64)9)V.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVEREPORT(LER)TEXTCONTINUATIONAPPAOVEDOMBNO.31500104EXP)RES:4/30/92ESiATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:508)HAS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETQTH'ERECORDSANDREPORTSMANAGEMENTBRANCH(PB30).V.S.NUCLEARREGULATORYCOMMISSION.WASHINGTON.OC20555.ANDTO1MEPAPERWORKAEDUCTIONPAO/ECT(315041041.OFFICEOFMANAGEMENTANOBUDGET,WASHINGTON.DC20503.FACILITYNAMEI1)DOCKETNUMBER(2)LERNUMBER(6)PAGE(3)YEARPINSEQUENTIALNUMBER<I'AREVISIONNUMBERD.C.CookNuclearPlant-Unit1TEXT//IIINeeepeeele/eeIeeN/Bee~////Bone/HRCFem)366A'4)(17)315920040004OF04Basedupontheaboveanalysis,thefailuretoperformthesurveillanceprocedurewithinthegraceperiodisnotconsideredtohavecreatedasignificantsafetyconcern,nordidthemissedsurveillancecreateasignificanthazardtothehealthandsafetyofthegeneralpublic.CorrectiveAction1.Followingtheidentificationthattheportionofthe1-OHP4030.STP.002Vsurveillanceprocedurehadnotbeenperformed,the1-OHP4030.STP.002Vsurveillanceprocedurewassatisfactorilycompleted.TheShiftSupervisorreviewedThefindingofthisinvestigationwiththeinvolvedUnitSupervisor.ThisreviewincludedadiscussionoftheUnitSupervisorresponsibilityandaccountabilityfortheperformanceanddocumentationofsurveillanceprocedures.TheOperationsDepartmentProductionSupervisorreviewedthefindingofthisinvestigationwiththeengineersinvolved.PreviousSimilaEventsAreviewoftheLicenseEventReportsdidnotidentifyasimilarevent.NRCFomI366A(64)9)  
,R.F.KroegerB.Walters-Ft.WayneNRCResidentInspector J.F.Stang-NRCJ.G.KepplerM.R.PadgettG.Charnoff, Escr.D.HahnXNPOS.J.Brewer/B.
~~~/6 ACCELERATEDDISRIBUTIONDEMONSTIONSYSTEMREGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ACCESSIONNBR:9205270001DOC.DATE:92/05/20NOTARIZED:NODOCKETFACIL:50-315DonaldC.CookNuclearPowerPlant,Unit1,IndianaM05000315AUTH.NAMEAUTHORAFFILIATIONSAMPSON,J.R.IndianaMichiganPowerCo.(formerlyIndiana6MichiganEleBLIND,A.A.IndianaMichiganPowerCo.(formerlyIndiana6MichiganEleRECIP.NAMERECIPIENTAFFILIATION
P.LauzauB.A.SvenssonQ'cOygagANg61SR NRCFORM366(649)FACILITYNAMElllVS.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)D.C.CookNuclearPlant-Unit1APPROVED0MBNO.3150410CEXPIRES:C/30I92ESTIMATED BURDENPERRESPONSETOCOLIPLYWTHTHISINFORMATION COLLECTION REOUEST.500HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMFNT BRANCH(F630),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON.
DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31$0C)10el.OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON.
DC20503.DOCKETNUMBER(2)PAE3050003151OF04TITLEIclEVENTOATK(5)MissedSurveillance onBoricAcidFlowPathduetoPersonnel ErrorDuringProcedure ReviewProcessREPORTDATE(7)OTHERFACILITIES INVOLVED(4)LERNUMBERLSIMONTHOAYYEARYEARSEOVENTIAL NVMSEIINVMSEIIREVOKEMON)'HOAYYEARFACILITYNAMESDOCKETNUMBFR(SI 05000042092920040005209205000OPERATING MODE(4)POWERLEYEL,899cR~'ro"'CV)O;r.carr.@20A02(SI20A05(e)()Ill)20A054)(1l(EI 20AOS(e)(I)(IIII20A054)(1)tlrl20.4054)(1 I(rl20AOS(cl50M(el)1) 50.34(c)(2) 50.73(e)(2) lll60734)l2)(9)50.73Iel(2)(lli)
LICENSEECONTACTFORTHISLER(12)50.73(el(2IGrl 60.73(el(2)
(rI50.734l(2Hrii) 60.73(e)12)
(rill)IAl50.734I(2I4lil)I5I50,7S(~)IS)(el0THERSOU(AEMENTSOF10CFR():IC>rrCCOnrOrmrrrOftnrfOIIOwinpl (11THISREPORTISSUBMITTED PURSUANTT73.71(SI73.7((c)OTHERISorc>fy>nAottrrctOelowrnrfInFret,HACFormSSSA>NAMEJ.R.Sampson,Operations Department TELEPHONE NUMBERAREACODE616465-5901 COMPLETEON!LINEFOREACHCOIAPONENT FAILUREDESCRIBED IHTHISREPORTIIS)CAUSESYSTEMCOMPONENT MANUFAC.TUAERFPOATABLF.
TONPAOSCAUSESYSTEM~~Xo..r;rlCOMPONENT MANUFAC.TUREAEPOATABLTONPAOSk~mc@o~5SUPPLEMENTAL REPORTEXPECTEDIICIYESllfyrt,compirtrEXPECPEI>
SVSMISSION DATEINOABSTRACTl(,lmittotc00torcrLIr.,rpproelmrtrly lilrrrntinplrtprtrtyPrwnttrn linwll14)EXPECTEDSUBMISSION DATE(15)MONTHDAYYEAROn4-20-92,contrarytoTechnical Specification (TS)4.1.2.2.a.l, theseven-day testtoprovetheoperability oftheborationflowpathsfromtherefueling waterstoragetankandtheboricacidstoragetankwasnotperformed asscheduled.
Thetestisaccomplished bycyclingeachtestablepower-operatedorautomatic valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillance wasidentified on4-24-92.Thesurveillance procedure wasimmediately performed.
Alltestacceptance criteriaweremet.Themissedsurveillance occurredasaresultofpersonnel errorduringthereviewprocess.Thefindingsofthiseventwerereviewedwiththeinvolvedpersonnel bytheirsupervisors.
NRCForm344(649)
NRCFORM3rrSA(689)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVEREPORT(LERITEXTCONTINUATION tAPPROVEDOMBNOr31504104EXPIRES:rU30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:500HRS.FORWARDCOMMENTSRFGARDING BURDENESTIMATETOTHERECORDSANOREPORTSMANAGEMENT BRANCH(P430).U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, OC20555,ANOTO1NEPAPERWORK REDUCTION PROJECT(3)500104),
OFFICEOFMANAGEMENT ANOBUDGET,WASHINGTON.
DC20503.FACILITYNAME(1)DOCKETNUMBKR(2)LERNUMBER(SlPAGE(3)YEARIISKDUKNTIAL;~
NUMSSRREVISIONNVMISIID.C.CookNuclearPlant-Unit1TEXT(Ifmorespeceisrer)rrirer(
IreeaAiiriorrei iVRCFormJSSAK)(IT)31592004-0002OF04Conditions PriortoOccurrence Unitone(U-1)inmodeoneat89.9Xpower.Unittwo(U-2)inmodesixatOXpower.DescritionofEventOn4-20-92,the1-OHP4030.STP.002V (Boration SystemValvePositionVerification andTesting)surveillance procedure wasnotperformed tosatisfytheTechnical Specification (TS)surveillance requirement 4.1.2.2.a.l forTS3.1.2.2(Reactivity ControlSystemsFlowPaths-Operation).
TS4.1.2.2.a.l requiresatleastoncepersevendaysthattheborationflowpathsfromtherefueling waterstoragetank(RWST)(EIIS/CB-TK) andtheboricacidstoragetank(BAST)(EIIS/CB-TK) beprovenoperablebycyclingeachtestablepower-operatedorautomatic valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillance procedure wasdiscovered byanOperations Department Engineeron4-24-92,Thesurveillance testwaslastperformed on4-13-92.TheTSactionstatement wasenteredat1255hoursandthe1-OHP4030.STP.002V surveillance procedure wasstarted,completed, andreviewedby1314hourson4-24-92.Areviewofthecompleted surveillance notedthatthesurveillance acceptance criteriaweresatisfied andtheactionstatement wasexitedatthistime.On4-20-92,theinvolvedUnitSupervisor (SeniorReactorOperator) reviewedthe1-OHP4030.STP.002V paperwork completed duringhisshift.Following thisreview,theUnitSupervisor recordedthecompleted sectionsofthe1-OHP4030.STP.002V surveillance procedure intheMasterSurveillance Schedule.
Whilerecording thecompleted sectionsofthesurveillance procedure justreviewed, theUnitSupervisor incorrectly recalledthattheweeklysurveillance sectionoftheprocedure hadbeencompleted andsignedofftheweeklysurveillance procedure ascomplete.
Following theperformance ofthesurveillances listedontheschedule, theOperations Department Engineering Sectionconductsareviewofthecompleted surveillance paperwork.
Duringthissurveillance paperwork review,theengineers identified on4-21-92thatthe1-OHP4030.STP.002V weeklysurveillance procedure sheetsweremissing.Upondiscovering thatNRCForm36SA(689)  
)ACFORM3nSA(64)9)U.S.NUC(.EARREGULATORY COMMISSION LICENSEEEVEREPORT(LER)TEXTCONTINUATION APPROVEQ0MBNO.31500104EXPIRES:4/30/92ESATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REOUESTI500HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(PJ)301.U.S.NUCLEARREGULATORY COMMISSION.
WASHINGTON, DC20555,ANDTO1'HEPAPERWORK REDUCTION PROJECT(3(500(041, OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON.
DC20503..FACILITYNAME(1)DOCKETNUMBER(2)LERNUMBER(6)YEAR'julSEQUENTIAL,g>I(g REVISIONNUMBSR'..:MUAISSRPAGE(3ID.C.CookNuclearPlant-Unit1TEXT///moreepeoeLsJe)rrie(L oee~NRCForrlr36SA'4)l)7)31592-004-00P30Fptheweeklysurveillance procedure sheetsweremissing,theengineers documented thattheweeklysurveillance procedure wasingracebyrecording thestatusinthegracesectionoftheSurveillance StatusSummaryReport.Althoughtheengineers identified thattheweeklysurveillance wasapparently ingraceduetothemissingpaperwork, theengineers didnotpursuefurtherwhythesurveillance procedure hadnotbeencompleted.
Thiswasbasedontheengineers'ast experience hadshownthatthecontrolroomoperators alsotrackincomplete surveillances andpursuethecompletion ofasurveillance beforethegraceperiodexpires.CauseofEventThecauseforthemissedsurveillance waspersonnel error.TheUnitSupervisor developed amindsetduringthesurveillance reviewthatthesurveillance wascompleted andtherefore signedoffthesurveillance procedure ascompleteontheschedule.
Inaddition, theengineers hadamindsetthatcontrolroomoperators recordandtracksurveillances ingraceandthatthecontrolroomoperators wereawarethatthesurveillance hadnotbeencompleted, orthatthepaperwork musthavebeenroutedtotheengineers andhadnotarrived.Therefore, theengineers didnotpursuefurtherthecompletion ofthesurveillance.
A~nalslsTechnical Specification (TS)4.1.2.2.a.l (Reactivity ControlSystemsFlowPaths-Operating) requiresatleastoncepersevendaystheborationflowpathsfromtherefueling waterstoragetank(RWST)andtheboricacidstoragetank(BAST)tobeprovenoperablebycyclingeachtestablepower-operated orautomatic valveintheflowpaththroughatleaseonecompletecycleoffulltravel.Thefailuretoperformthesurveillance isaviolation ofTechnical Specification 3.1.2.2andisreportable under10CFR50.73(a)(2)(i)(B).
Following theidentification ofthemissedsurveillance, the1-OHP4030.STP.002V surveillance procedure wasperformed tosatisfytherequirements ofTS4.1.2.2.a.l.
Areviewofthecompleted surveillance notedthattherequirements ofthesurveillance procedure weremet.Therefore, itisconcluded thatthevalvestestedbythesurveillance procedure wouldhaveperformed theirsafetyfunctionifrequiredduringthetimeperiodfromthelastcompleted surveillance procedure on4-13-92andthesurveillance procedure performed on4-24-92.NR0Form366A(6419)
I/RCFOR)4A(64)9)V.S.NUCLEARREGULATORY COMMISSION LICENSEEEVEREPORT(LER)TEXTCONTINUATION APPAOVEDOMBNO.31500104EXP)RES:4/30/92ESiATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:508)HAS.FORWARDCOMMENTSREGARDING BURDENESTIMATETQTH'ERECORDSANDREPORTSMANAGEMENT BRANCH(PB30).V.S.NUCLEARREGULATORY COMMISSION.
WASHINGTON.
OC20555.ANDTO1MEPAPERWORK AEDUCTION PAO/ECT(315041041.
OFFICEOFMANAGEMENT ANOBUDGET,WASHINGTON.
DC20503.FACILITYNAMEI1)DOCKETNUMBER(2)LERNUMBER(6)PAGE(3)YEARPINSEQUENTIAL NUMBER<I'AREVISIONNUMBERD.C.CookNuclearPlant-Unit1TEXT//IIINeeepeeele/eeIeeN/Bee~////Bone/HRC Fem)366A'4)(17)315920040004OF04Basedupontheaboveanalysis, thefailuretoperformthesurveillance procedure withinthegraceperiodisnotconsidered tohavecreatedasignificant safetyconcern,nordidthemissedsurveillance createasignificant hazardtothehealthandsafetyofthegeneralpublic.Corrective Action1.Following theidentification thattheportionofthe1-OHP4030.STP.002V surveillance procedure hadnotbeenperformed, the1-OHP4030.STP.002V surveillance procedure wassatisfactorily completed.
TheShiftSupervisor reviewedThefindingofthisinvestigation withtheinvolvedUnitSupervisor.
Thisreviewincludedadiscussion oftheUnitSupervisor responsibility andaccountability fortheperformance anddocumentation ofsurveillance procedures.
TheOperations Department Production Supervisor reviewedthefindingofthisinvestigation withtheengineers involved.
PreviousSimilaEventsAreviewoftheLicenseEventReportsdidnotidentifyasimilarevent.NRCFomI366A(64)9)  
~~~/6 ACCELERATED DISRIBUTIONDEMONSTIONSYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESSION NBR:9205270001 DOC.DATE:
92/05/20NOTARIZED:
NODOCKETFACIL:50-315 DonaldC.CookNuclearPowerPlant,Unit1,IndianaM05000315AUTH.NAMEAUTHORAFFILIATION SAMPSON,J.R.
IndianaMichiganPowerCo.(formerly Indiana6MichiganEleBLIND,A.A.
IndianaMichiganPowerCo.(formerly Indiana6MichiganEleRECIP.NAME RECIPIENT AFFILIATION


==SUBJECT:==
==SUBJECT:==
LER92-004-00:on920420,7-daytesttoproveoperabilityofborationflowpathsfromrefuelingwaterstorage6boricacidstoragetanksnotperformedasscheduled.Causedbypersonnelerror.Testsuccessfullyperformed.W/920520ltr.DISTRIBUTIONCODE:IE22TCOPIESRECEIVED:LTRIENCLJSIZE:STITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.NOTES:DRECIPIENTIDCODE/NAMEPD3-1LASTANG,JINTERNAL'CNWAEOD/DSP/TPABNRR/DET/EMEB7ENRR/DLPQ/LPEB10NRR/DREP/PRPB11NRR/DST/SICBSH3NRR/DST/SRXBSERES/DSIR/EIBEXTERNALEGGGBRYCEgJ~HNRCPDRNSICPOOREgW~COPIESLTTRENCL11112211111122111111331111RECIPIENTIDCODE/NAMEPD3-1PDAEOD/DOAAEOD/ROAB/DSPNRR/DLPQ/LHFB10NRR/DOEA/OEABNRR/DST/SELBSDNRRSDPLBSD1G~E02RGN3FILE01LSTLOBBYWARDNSICMURPHY,G.ANUDOCSFULLTXTCOPIESLTTRENCL111122111111111111111111DDDNOTETOALL"RIDS"RECIPIENTS:PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELMINATEYOURNAMEFROMDISTRIBUTIONLISTSFORDOCUMENTSYOUDON'TNEED!DDFULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR30ENCL30 IndianaMichiganPowerCompanyCookNuclearPlant~OneCookPlaceBridgman,Ml491066164655901May20,1992INDUNANICMGAMPOPOVERUnitedStatesNuclearRegulatoryCommissionDocumentControlDeskRockville,Maryland20852OperatingLicensesDPR-58DocketNo.50-315DocumentControlManager:Inaccordancewiththecriteriaestablishedby10CFR50.73entitledLicenseeEventReortSstemthefollowingreportisbeingsubmitted:92-004-00Sincerely,A.A.BlindPlantManager/sbAttachmentc:D.H.Williams,Jr.A.B.Davis,RegionIIIE.E.FitzpatrickP.A.BarrettB.F.HendersonR.F.KroegerB.Walters-Ft.WayneNRCResidentInspectorJ.F.Stang-NRCJ.G.KepplerM.R.PadgettG.Charnoff,Esq.D.HahnINPOS.J.Brewer/B.P.LauzauB.A.Svensson920527000i920520PDRADOCK05000315SPDR
LER92-004-00:on 920420,7-day testtoproveoperability ofborationflowpathsfromrefueling waterstorage6boricacidstoragetanksnotperformed asscheduled.
Causedbypersonnel error.Testsuccessfully performed.W/920520 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR IENCLJSIZE:STITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:DRECIPIENT IDCODE/NAME PD3-1LASTANG,JINTERNAL'CNW AEOD/DSP/TPABNRR/DET/EMEB 7ENRR/DLPQ/LPEB10 NRR/DREP/PRPB11 NRR/DST/SICBSH3 NRR/DST/SRXB SERES/DSIR/EIB EXTERNALEGGGBRYCEgJ~HNRCPDRNSICPOOREgW~COPIESLTTRENCL11112211111122111111331111RECIPIENT IDCODE/NAME PD3-1PDAEOD/DOAAEOD/ROAB/DSP NRR/DLPQ/LHFB10 NRR/DOEA/OEAB NRR/DST/SELB SDNRRSDPLBSD1G~E02RGN3FILE01LSTLOBBYWARDNSICMURPHY,G.A NUDOCSFULLTXTCOPIESLTTRENCL111122111111111111111111DDDNOTETOALL"RIDS"RECIPIENTS:
PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELMINATEYOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!DDFULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:
LTTR30ENCL30 IndianaMichiganPowerCompanyCookNuclearPlant~OneCookPlaceBridgman, Ml491066164655901May20,1992INDUNANICMGAMPOPOVERUnitedStatesNuclearRegulatory Commission DocumentControlDeskRockville, Maryland20852Operating LicensesDPR-58DocketNo.50-315DocumentControlManager:Inaccordance withthecriteriaestablished by10CFR50.73entitledLicenseeEventReortSstemthefollowing reportisbeingsubmitted:
92-004-00 Sincerely, A.A.BlindPlantManager/sbAttachment c:D.H.Williams, Jr.A.B.Davis,RegionIIIE.E.Fitzpatrick P.A.BarrettB.F.Henderson R.F.KroegerB.Walters-Ft.WayneNRCResidentInspector J.F.Stang-NRCJ.G.KepplerM.R.PadgettG.Charnoff, Esq.D.HahnINPOS.J.Brewer/B.
P.LauzauB.A.Svensson920527000i 920520PDRADOCK05000315SPDR


NRCFORM346(64)9)FACILITYNAME(I)V.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)D.C.CookNuclearPlant-Unit1tAPPROVEDOMBNO.31504)104EXPIRES:4I30192ESTIMATEDBURDENPEARESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONAEOUESTt50.0HRS.FORWAADCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENTBRANCH(PPr30),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555,ANDTOTHEPAPERWORKREDUCTIONPROJECT(31500104),OFFICEOFMANAGEMENTANDBUDGET)WASHINGTON,DC20503.DOCKETNUMBERl2)PAGE.3050003]51OF04TITLE(4)MissedSurveillanceonBoricAcidFlowPathduetoPersonnelErrorDuringProcedureReviewProcessEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIESINVOLVED(4)MONTHOAYYEARYEARSEOVENTIALopnNVMSEANVMSESIMONTHDAYYEARFACILITYNAMESDOCKETNUMBER(SI05000042092920040005209205000OPERATINGMODE(SljPOWERLEYEL899))Wv@~<20802(S)20.4061~)Ill(il20.405(eI(1l(ii)20.406(~)(1)(15)20AOS(el(1l(ivt20.405(el(1)lvl20AOS(c)50.34(cl(1)50.34(cl(2)X60.73(~)(2)ill50,73(e)(2)liil50.73(e)(2((iil)LICENSEECONTACTFORTHISLEA(12I50.73(e)(2)liv)50.73(~)(2)(vlS0,73(~)LEI(viil60.73(e)(2)(viii)(A)50.73(el(2)(viiil(BI60.73(~I(2)(elTHISREPORTISSUBMITTEDPURSUANTTOTHEREOUIREMENTSOF10CFRg:(Cn<<4onrormorroftnrIollowinPI(11)73.71(S)73.71(clDTHER(speedysnAostrrctOrlrvvrmlinTrit,NRCForm388AINAMEJ.R.Sampson,OperationsDepartmentTELEPHONENUMBERAREACODE616465-5901COMPLETEONELINEFOREACHCOMPONENTFAILUREDESCRIBEDINTHISAEPOAT113)CAUSESYSTEMCOMPONENTMANUFAC.TVREREPORTABLETONPADSaI(SI~BP;CAUSESYSTEMCOMPONENTMANUFAC-TIJRER~OP)BILn'(IQ<".4SVPPLEMENTALREPORTEXPECTED(14)EXPECTEDSUBMISSIONDATE(15)klan%~'~MONTHDAYYEARYESllfyrs,complrtrEXPECTEDSIIEMISSIOIIDATEJNOABsTRAcT(Limittof400sprees,Ir.,rppioxlmrtrlpliltrrnslnclrspreetvprwrittrnlinrsl(14)On4-20-92,contrarytoTechnicalSpecification(TS)4.1.2.2.a.l,theseven-daytesttoprovetheoperabilityoftheborationflowpathsfromtherefuelingwaterstoragetankandtheboricacidstoragetankwasnotperformedasscheduled.Thetestisaccomplishedbycyclingeachtestablepower-operatedorautomatic'valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillancewasidentifiedon4-24-92.Thesurveillanceprocedurewasimmediatelyperformed.Alltestacceptancecriteriaweremet.Themissedsurveillanceoccurredasaresultofpersonnelerrorduringthereviewprocess.Thefindingsofthiseventwerereviewedwiththeinvolvedpersonnelbytheirsupervisors.NRCFosses346(64)9)
NRCFORM346(64)9)FACILITYNAME(I)V.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)D.C.CookNuclearPlant-Unit1tAPPROVEDOMBNO.31504)104 EXPIRES:4I30192ESTIMATED BURDENPEARESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION AEOUESTt50.0HRS.FORWAADCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(PPr30),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31500104),
NRCFORM366A(64)9)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONtAPPROVEDOMBNO.31504104EXPIRES:4/30/92ESTIMATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENTBRANCH(P.530),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON.DC20555,ANDTO1'HEPAPERWORKREDUCTIONPROJECT(31500104),OFFICEOFMANAGEMENTANDBUDGET,WASHINGTON,DC20503.FACILITYNAME(1)DOCKETNUMBER(2)YEARLERNUMBER(6)SEQUENTIALNUMBERREVISIONNVMBERPAGE(3)D.C.CookNuclearPlant-Unit1TEXT///moro4O4co/4roqo/rod,IrJoodds/orM/HRCForm36649/(17)050003]590040002QF0ConditionsPriortoOccurrenceUnitone(U-1)inmodeoneat89.9Xpower.Unittwo(U-2)inmodesixatOXpower.DescritionofEventOn4-20-92,the1-OHP4030.STP.002V(BorationSystemValvePositionVerificationandTesting)surveillanceprocedurewasnotperformedtosatisfytheTechnicalSpecification(TS)surveillancerequirement4.1.2.2.a.lforTS3.1.2.2(ReactivityControlSystemsFlowPaths-Operation).TS4.1.2.2.a.lrequiresatleastoncepersevendaysthattheborationflowpathsfromtherefuelingwaterstoragetank(RWST)(EIIS/CB-TK)andtheboricacidstoragetank(BAST)(EIIS/CB-TK)beprovenoperablebycyclingeachtestablepower-operatedorautomaticvalveintheflowpaththroughatleastonecompletecycleoffulltravel.ThemissedsurveillanceprocedurewasdiscoveredbyanOperationsDepartmentEngineeron4-24-92.Thesurveillancetestwaslastperformedon4-13-92.TheTSactionstatementwasenteredat1255hoursandthe1-OHP4030.STP.002Vsurveillanceprocedurewasstarted,completed,andreviewedby1314hourson4-24-92.Areviewofthecompletedsurveillancenotedthatthesurveillanceacceptancecriteriaweresatisfiedandtheactionstatementwasexitedatthistime.On4-20-92,theinvolvedUnitSupervisor(SeniorReactorOperator)reviewedthe1-OHP4030.STP.002Vpaperworkcompletedduringhisshift.Followingthisreview,theUnitSupervisorrecordedthecompletedsectionsofthe1-OHP4030.STP.002VsurveillanceprocedureintheMasterSurveillanceSchedule.Whilerecordingthecompletedsectionsofthesurveillanceprocedurejustreviewed,theUnitSupervisorincorrectlyrecalledthattheweeklysurveillancesectionoftheprocedurehadbeencompletedandsignedofftheweeklysurveillanceprocedureascomplete.Followingtheperformanceofthesurveillanceslistedontheschedule,theOperationsDepartmentEngineeringSectionconductsareviewofthecompletedsurveillancepaperwork.Duringthissurveillancepaperworkreview,theengineersidentifiedon4-21-92thatthe1-OHP4030.STP.002Vweeklysurveillanceproceduresheetsweremissing.UpondiscoveringthatNRCForm366A(64)9)
OFFICEOFMANAGEMENT ANDBUDGET)WASHINGTON, DC20503.DOCKETNUMBERl2)PAGE.3050003]51OF04TITLE(4)MissedSurveillance onBoricAcidFlowPathduetoPersonnel ErrorDuringProcedure ReviewProcessEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIES INVOLVED(4)MONTHOAYYEARYEARSEOVENTIAL opnNVMSEANVMSESIMONTHDAYYEARFACILITYNAMESDOCKETNUMBER(SI 05000042092920040005209205000OPERATING MODE(SljPOWERLEYEL899))Wv@~<20802(S)20.4061~)Ill(il20.405(eI(1l(ii)20.406(~)(1)(15)20AOS(el(1 l(ivt20.405(el(1) lvl20AOS(c)50.34(cl(1) 50.34(cl(2)
NRCFORM366A(64)9)UILNUCLEARREGULATORYCOMMISSIONLICENSEEEVENEPORT(LER)TEXTCONTINUATIONAPPROVEDOMBNO.31500104EXPIRESI4/30/92ESTIEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:50.0HAS,FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENTBRANCH(P-530).V.S.NVCI.EARREGULATORYCOMMISSION,WASHINGTON.DC20555,ANDTO1'HEPAPERWORKREDUCTIONPROJECT(31500104),OFFICEOFMANAGEMENTANDBUDGET,WASHINGTON,DC20503.FACILITYNAME(1)DOCKETNUMBER(2)YEARLERNUMBER(6)SEOVENTIALNUMSERREVISIONNUMBERPAGE(3)D.C.CookNuclearPlant-Unit1TEXT/l/moroEpoco/1rorlur)od,urooddldooo/NRCForm36649/07)050003]5920040003QF0theweeklysurveillanceproceduresheetsweremissing,theengineersdocumentedthattheweeklysurveillanceprocedurewasingracebyrecordingthestatusinthegracesectionoftheSurveillanceStatusSummaryReport.Althoughtheengineersidentifiedthattheweeklysurveillancewasapparentlyingraceduetothemissingpaperwork,theengineersdidnotpursuefurtherwhythesurveillanceprocedurehadnotbeencompleted.Thiswasbasedontheengineers'astexperiencehadshownthatthecontrolroomoperatorsalsotrackincompletesurveillancesandpursuethecompletionofasurveillancebeforethegraceperiodexpires.CauseofEventThecauseforthemissedsurveillancewaspersonnelerror.TheUnitSupervisordevelopedamindsetduringthesurveillancereviewthatthesurveillancewascompletedandthereforesignedoffthesurveillanceprocedureascompleteontheschedule.Inaddition,theengineershadamindsetthatcontrolroomoperatorsrecordandtracksurveillancesingraceandthatthecontrolroomoperatorswereawarethatthesurveillancehadnotbeencompleted,orthatthepaperworkmusthavebeenroutedtotheengineersandhadnotarrived.Therefore,theengineersdidnotpursuefurtherthecompletionofthesurveillance.A~nalsisTechnicalSpecification(TS)4.1.2.2.a.l(ReactivityControlSystemsFlowPaths-Operating)requiresatleastoncepersevendaystheborationflowpathsfromtherefuelingwaterstoragetank(RWST)andtheboricacidstoragetank(BAST)tobeprovenoperablebycyclingeachtestablepower-operatedorautomaticvalveintheflowpaththroughatleastonecompletecycleoffulltravel.ThefailuretoperformthesurveillanceisaviolationofTechnicalSpecification3.1.2.2andisreportableunder10CFR50s73(a)(2)(i)(B).Followingtheidentificationofthemissedsurveillance,the1-OHP4030.STP.002VsurveillanceprocedurewasperformedtosatisfytherequirementsofTS4.1.2.2.a.l.Areviewofthecompletedsurveillancenotedthattherequirementsofthesurveillanceprocedureweremet.Therefore,itisconcludedthatthevalvestestedbythesurveillanceprocedurewouldhaveperformedtheirsafetyfunctionifrequiredduringthetimeperiodfromthelastcompletedsurveillanceprocedureon4-13-92andthesurveillanceprocedureperformedon4-24-92.NACForm366A(84)9)
X60.73(~)(2)ill50,73(e)(2) liil50.73(e)(2((iil)
NRCFORM366A(64)9)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENEPORT(LER)TEXTCONTINUATIONAPPROVEDOMBNO.31504(04EXPIRESI4/30/02ESTIFDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:500HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENTBRANCH(P430),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555,ANDTOTHEPAPERWORKREDUCTIONPROJECT(31500104),OFFICEOFMANAGEMENTANDBUDGET,WASHINGTON,DC20503.FACILITYNAME(1)~DOCKETNUMBER(2)LERNUMBER(6)PAGE(3)D.C.CookNuclearPlant-Unit1TEXTNmorttrrtctisttqur)td,u>>4ddrrr'ootrHRCForm3664'tll)7)YEAR31592SEQUENTIAI.NUMBER0045+(REVISIONNUMBER00040F0Basedupontheaboveanalysis,thefailuretoperformthesurveillanceprocedurewithinthegraceperiodisnotconsideredtohavecreatedasignificantsafetyconcern,nordidthemissedsurveillancecreateasignificanthazardtothehealthandsafetyofthegeneralpublic.CorrectiveActionFollowingtheidentificationthattheportionofthe1-OHP4030.STP.002Vsurveillanceprocedurehadnotbeenperformed,the1-OHP4030~STP.002Vsurveillanceprocedurewassatisfactorilycompleted.2.TheShiftSupervisorreviewedThefindingofthisinvestigationwiththeinvolvedUnitSupervisor.ThisreviewincludedadiscussionoftheUnitSupervisorresponsibilityandaccountabilityfortheperformanceanddocumentationofsurveillanceprocedures.3.TheOperationsDepartmentProductionSupervisor,reviewedthefindingofthis.investigationwiththeengineersinvolved.PreviousSimilarEventsAreviewoftheLicenseEventReportsdidnotidentifyasimilarevent.NRCForm366A(64)B)}}
LICENSEECONTACTFORTHISLEA(12I50.73(e)(2)liv)50.73(~)(2)(vlS0,73(~)LEI(viil60.73(e)(2)(viii)(A)50.73(el(2)(viiil(BI 60.73(~I(2)(elTHISREPORTISSUBMITTED PURSUANTTOTHEREOUIREMENTS OF10CFRg:(Cn<<4onrormorroftnrIollowinPI (11)73.71(S)73.71(clDTHER(speedysnAostrrctOrlrvvrmlin Trit,NRCForm388AINAMEJ.R.Sampson,Operations Department TELEPHONE NUMBERAREACODE616465-5901 COMPLETEONELINEFOREACHCOMPONENT FAILUREDESCRIBED INTHISAEPOAT113)CAUSESYSTEMCOMPONENT MANUFAC.TVREREPORTABLE TONPADSaI(SI~BP; CAUSESYSTEMCOMPONENT MANUFAC-TIJRER~OP)BILn'(IQ<".4 SVPPLEMENTAL REPORTEXPECTED(14)EXPECTEDSUBMISSION DATE(15)klan%~'~MONTHDAYYEARYESllfyrs,complrtrEXPECTEDSIIEMISSIOII DATEJNOABsTRAcT(Limittof400sprees,Ir.,rppioxlmrtrlp liltrrnslnclrspreetvprwrittrnlinrsl(14)On4-20-92,contrarytoTechnical Specification (TS)4.1.2.2.a.l, theseven-day testtoprovetheoperability oftheborationflowpathsfromtherefueling waterstoragetankandtheboricacidstoragetankwasnotperformed asscheduled.
Thetestisaccomplished bycyclingeachtestablepower-operatedorautomatic
'valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillance wasidentified on4-24-92.Thesurveillance procedure wasimmediately performed.
Alltestacceptance criteriaweremet.Themissedsurveillance occurredasaresultofpersonnel errorduringthereviewprocess.Thefindingsofthiseventwerereviewedwiththeinvolvedpersonnel bytheirsupervisors.
NRCFosses346(64)9)
NRCFORM366A(64)9)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION tAPPROVEDOMBNO.31504104EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:50.0HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(P.530),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON.
DC20555,ANDTO1'HEPAPERWORK REDUCTION PROJECT(31500104),
OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(1)DOCKETNUMBER(2)YEARLERNUMBER(6)SEQUENTIAL NUMBERREVISIONNVMBERPAGE(3)D.C.CookNuclearPlant-Unit1TEXT///moro4O4co/4roqo/rod, IrJoodds/orM/HRC Form36649/(17)050003]590040002QF0Conditions PriortoOccurrence Unitone(U-1)inmodeoneat89.9Xpower.Unittwo(U-2)inmodesixatOXpower.DescritionofEventOn4-20-92,the1-OHP4030.STP.002V (Boration SystemValvePositionVerification andTesting)surveillance procedure wasnotperformed tosatisfytheTechnical Specification (TS)surveillance requirement 4.1.2.2.a.l forTS3.1.2.2(Reactivity ControlSystemsFlowPaths-Operation).
TS4.1.2.2.a.l requiresatleastoncepersevendaysthattheborationflowpathsfromtherefueling waterstoragetank(RWST)(EIIS/CB-TK) andtheboricacidstoragetank(BAST)(EIIS/CB-TK) beprovenoperablebycyclingeachtestablepower-operatedorautomatic valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillance procedure wasdiscovered byanOperations Department Engineeron4-24-92.Thesurveillance testwaslastperformed on4-13-92.TheTSactionstatement wasenteredat1255hoursandthe1-OHP4030.STP.002V surveillance procedure wasstarted,completed, andreviewedby1314hourson4-24-92.Areviewofthecompleted surveillance notedthatthesurveillance acceptance criteriaweresatisfied andtheactionstatement wasexitedatthistime.On4-20-92,theinvolvedUnitSupervisor (SeniorReactorOperator) reviewedthe1-OHP4030.STP.002V paperwork completed duringhisshift.Following thisreview,theUnitSupervisor recordedthecompleted sectionsofthe1-OHP4030.STP.002V surveillance procedure intheMasterSurveillance Schedule.
Whilerecording thecompleted sectionsofthesurveillance procedure justreviewed, theUnitSupervisor incorrectly recalledthattheweeklysurveillance sectionoftheprocedure hadbeencompleted andsignedofftheweeklysurveillance procedure ascomplete.
Following theperformance ofthesurveillances listedontheschedule, theOperations Department Engineering Sectionconductsareviewofthecompleted surveillance paperwork.
Duringthissurveillance paperwork review,theengineers identified on4-21-92thatthe1-OHP4030.STP.002V weeklysurveillance procedure sheetsweremissing.Upondiscovering thatNRCForm366A(64)9)
NRCFORM366A(64)9)UILNUCLEARREGULATORY COMMISSION LICENSEEEVENEPORT(LER)TEXTCONTINUATION APPROVEDOMBNO.31500104EXPIRESI4/30/92ESTIEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:50.0HAS,FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(P-530).V.S.NVCI.EARREGULATORY COMMISSION, WASHINGTON.
DC20555,ANDTO1'HEPAPERWORK REDUCTION PROJECT(31500104),
OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(1)DOCKETNUMBER(2)YEARLERNUMBER(6)SEOVENTIAL NUMSERREVISIONNUMBERPAGE(3)D.C.CookNuclearPlant-Unit1TEXT/l/moroEpoco/1rorlur)od, urooddldooo/
NRCForm36649/07)050003]5920040003QF0theweeklysurveillance procedure sheetsweremissing,theengineers documented thattheweeklysurveillance procedure wasingracebyrecording thestatusinthegracesectionoftheSurveillance StatusSummaryReport.Althoughtheengineers identified thattheweeklysurveillance wasapparently ingraceduetothemissingpaperwork, theengineers didnotpursuefurtherwhythesurveillance procedure hadnotbeencompleted.
Thiswasbasedontheengineers'ast experience hadshownthatthecontrolroomoperators alsotrackincomplete surveillances andpursuethecompletion ofasurveillance beforethegraceperiodexpires.CauseofEventThecauseforthemissedsurveillance waspersonnel error.TheUnitSupervisor developed amindsetduringthesurveillance reviewthatthesurveillance wascompleted andtherefore signedoffthesurveillance procedure ascompleteontheschedule.
Inaddition, theengineers hadamindsetthatcontrolroomoperators recordandtracksurveillances ingraceandthatthecontrolroomoperators wereawarethatthesurveillance hadnotbeencompleted, orthatthepaperwork musthavebeenroutedtotheengineers andhadnotarrived.Therefore, theengineers didnotpursuefurtherthecompletion ofthesurveillance.
A~nalsisTechnical Specification (TS)4.1.2.2.a.l (Reactivity ControlSystemsFlowPaths-Operating) requiresatleastoncepersevendaystheborationflowpathsfromtherefueling waterstoragetank(RWST)andtheboricacidstoragetank(BAST)tobeprovenoperablebycyclingeachtestablepower-operated orautomatic valveintheflowpaththroughatleastonecompletecycleoffulltravel.Thefailuretoperformthesurveillance isaviolation ofTechnical Specification 3.1.2.2andisreportable under10CFR50s73(a)(2)(i)(B).
Following theidentification ofthemissedsurveillance, the1-OHP4030.STP.002V surveillance procedure wasperformed tosatisfytherequirements ofTS4.1.2.2.a.l.
Areviewofthecompleted surveillance notedthattherequirements ofthesurveillance procedure weremet.Therefore, itisconcluded thatthevalvestestedbythesurveillance procedure wouldhaveperformed theirsafetyfunctionifrequiredduringthetimeperiodfromthelastcompleted surveillance procedure on4-13-92andthesurveillance procedure performed on4-24-92.NACForm366A(84)9)
NRCFORM366A(64)9)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENEPORT(LER)TEXTCONTINUATION APPROVEDOMBNO.31504(04EXPIRESI4/30/02ESTIFDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:500HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(P430),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31500104),
OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(1)~DOCKETNUMBER(2)LERNUMBER(6)PAGE(3)D.C.CookNuclearPlant-Unit1TEXTNmorttrrtctisttqur)td, u>>4ddrrr'ootr HRCForm3664'tll)7)YEAR31592SEQUENTIAI.
NUMBER0045+(REVISIONNUMBER00040F0Basedupontheaboveanalysis, thefailuretoperformthesurveillance procedure withinthegraceperiodisnotconsidered tohavecreatedasignificant safetyconcern,nordidthemissedsurveillance createasignificant hazardtothehealthandsafetyofthegeneralpublic.Corrective ActionFollowing theidentification thattheportionofthe1-OHP4030.STP.002V surveillance procedure hadnotbeenperformed, the1-OHP4030~STP.002Vsurveillance procedure wassatisfactorily completed.
2.TheShiftSupervisor reviewedThefindingofthisinvestigation withtheinvolvedUnitSupervisor.
Thisreviewincludedadiscussion oftheUnitSupervisor responsibility andaccountability fortheperformance anddocumentation ofsurveillance procedures.
3.TheOperations Department Production Supervisor, reviewedthefindingofthis.investigation withtheengineers involved.
PreviousSimilarEventsAreviewoftheLicenseEventReportsdidnotidentifyasimilarevent.NRCForm366A(64)B)}}

Revision as of 08:36, 29 June 2018

LER 92-004-00:on 920420,7-day Test to Prove Operability of Boration Flow Paths from Refueling Water Storage & Boric Acid Storage Tanks Not Performed as Scheduled.Caused by Personnel Error.Test Successfully performed.W/920520 Ltr
ML17329A515
Person / Time
Site: Cook American Electric Power icon.png
Issue date: 05/20/1992
From: BLIND A A, SAMPSON J R
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)
v • d • e


Text

1!ndianaMichiganPowerCompanyCookNuc!earP!ant".neCookPlaceBridgman.

Ml~91066164655901May20,1992diagINDIANJLNlCHlG4NPOWERUnitedStatesNuclearRegulatory Commission DocumentControlDeskRockville, Maryland20852Operating LicensesDPR-58DocketNo.50-315DocumentControlManager:lnaccordance withthecriteriaestablished by10CFR50.73entitledLicenseeEventReortSstemthefollowing reportisbeingsubmitted:

92-004-00 Sincerely, A.A.BlindPlantManager/sbAttachment cD.H.Williams, Jr.tA.B..Davis.,Region~?Q'.E.Fitzpatrick P.A.BarrettB.F.Henderson

,R.F.KroegerB.Walters-Ft.WayneNRCResidentInspector J.F.Stang-NRCJ.G.KepplerM.R.PadgettG.Charnoff, Escr.D.HahnXNPOS.J.Brewer/B.

P.LauzauB.A.SvenssonQ'cOygagANg61SR NRCFORM366(649)FACILITYNAMElllVS.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)D.C.CookNuclearPlant-Unit1APPROVED0MBNO.3150410CEXPIRES:C/30I92ESTIMATED BURDENPERRESPONSETOCOLIPLYWTHTHISINFORMATION COLLECTION REOUEST.500HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMFNT BRANCH(F630),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON.

DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31$0C)10el.OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON.

DC20503.DOCKETNUMBER(2)PAE3050003151OF04TITLEIclEVENTOATK(5)MissedSurveillance onBoricAcidFlowPathduetoPersonnel ErrorDuringProcedure ReviewProcessREPORTDATE(7)OTHERFACILITIES INVOLVED(4)LERNUMBERLSIMONTHOAYYEARYEARSEOVENTIAL NVMSEIINVMSEIIREVOKEMON)'HOAYYEARFACILITYNAMESDOCKETNUMBFR(SI 05000042092920040005209205000OPERATING MODE(4)POWERLEYEL,899cR~'ro"'CV)O;r.carr.@20A02(SI20A05(e)()Ill)20A054)(1l(EI 20AOS(e)(I)(IIII20A054)(1)tlrl20.4054)(1 I(rl20AOS(cl50M(el)1) 50.34(c)(2) 50.73(e)(2) lll60734)l2)(9)50.73Iel(2)(lli)

LICENSEECONTACTFORTHISLER(12)50.73(el(2IGrl 60.73(el(2)

(rI50.734l(2Hrii) 60.73(e)12)

(rill)IAl50.734I(2I4lil)I5I50,7S(~)IS)(el0THERSOU(AEMENTSOF10CFR():IC>rrCCOnrOrmrrrOftnrfOIIOwinpl (11THISREPORTISSUBMITTED PURSUANTT73.71(SI73.7((c)OTHERISorc>fy>nAottrrctOelowrnrfInFret,HACFormSSSA>NAMEJ.R.Sampson,Operations Department TELEPHONE NUMBERAREACODE616465-5901 COMPLETEON!LINEFOREACHCOIAPONENT FAILUREDESCRIBED IHTHISREPORTIIS)CAUSESYSTEMCOMPONENT MANUFAC.TUAERFPOATABLF.

TONPAOSCAUSESYSTEM~~Xo..r;rlCOMPONENT MANUFAC.TUREAEPOATABLTONPAOSk~mc@o~5SUPPLEMENTAL REPORTEXPECTEDIICIYESllfyrt,compirtrEXPECPEI>

SVSMISSION DATEINOABSTRACTl(,lmittotc00torcrLIr.,rpproelmrtrly lilrrrntinplrtprtrtyPrwnttrn linwll14)EXPECTEDSUBMISSION DATE(15)MONTHDAYYEAROn4-20-92,contrarytoTechnical Specification (TS)4.1.2.2.a.l, theseven-day testtoprovetheoperability oftheborationflowpathsfromtherefueling waterstoragetankandtheboricacidstoragetankwasnotperformed asscheduled.

Thetestisaccomplished bycyclingeachtestablepower-operatedorautomatic valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillance wasidentified on4-24-92.Thesurveillance procedure wasimmediately performed.

Alltestacceptance criteriaweremet.Themissedsurveillance occurredasaresultofpersonnel errorduringthereviewprocess.Thefindingsofthiseventwerereviewedwiththeinvolvedpersonnel bytheirsupervisors.

NRCForm344(649)

NRCFORM3rrSA(689)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVEREPORT(LERITEXTCONTINUATION tAPPROVEDOMBNOr31504104EXPIRES:rU30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:500HRS.FORWARDCOMMENTSRFGARDING BURDENESTIMATETOTHERECORDSANOREPORTSMANAGEMENT BRANCH(P430).U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, OC20555,ANOTO1NEPAPERWORK REDUCTION PROJECT(3)500104),

OFFICEOFMANAGEMENT ANOBUDGET,WASHINGTON.

DC20503.FACILITYNAME(1)DOCKETNUMBKR(2)LERNUMBER(SlPAGE(3)YEARIISKDUKNTIAL;~

NUMSSRREVISIONNVMISIID.C.CookNuclearPlant-Unit1TEXT(Ifmorespeceisrer)rrirer(

IreeaAiiriorrei iVRCFormJSSAK)(IT)31592004-0002OF04Conditions PriortoOccurrence Unitone(U-1)inmodeoneat89.9Xpower.Unittwo(U-2)inmodesixatOXpower.DescritionofEventOn4-20-92,the1-OHP4030.STP.002V (Boration SystemValvePositionVerification andTesting)surveillance procedure wasnotperformed tosatisfytheTechnical Specification (TS)surveillance requirement 4.1.2.2.a.l forTS3.1.2.2(Reactivity ControlSystemsFlowPaths-Operation).

TS4.1.2.2.a.l requiresatleastoncepersevendaysthattheborationflowpathsfromtherefueling waterstoragetank(RWST)(EIIS/CB-TK) andtheboricacidstoragetank(BAST)(EIIS/CB-TK) beprovenoperablebycyclingeachtestablepower-operatedorautomatic valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillance procedure wasdiscovered byanOperations Department Engineeron4-24-92,Thesurveillance testwaslastperformed on4-13-92.TheTSactionstatement wasenteredat1255hoursandthe1-OHP4030.STP.002V surveillance procedure wasstarted,completed, andreviewedby1314hourson4-24-92.Areviewofthecompleted surveillance notedthatthesurveillance acceptance criteriaweresatisfied andtheactionstatement wasexitedatthistime.On4-20-92,theinvolvedUnitSupervisor (SeniorReactorOperator) reviewedthe1-OHP4030.STP.002V paperwork completed duringhisshift.Following thisreview,theUnitSupervisor recordedthecompleted sectionsofthe1-OHP4030.STP.002V surveillance procedure intheMasterSurveillance Schedule.

Whilerecording thecompleted sectionsofthesurveillance procedure justreviewed, theUnitSupervisor incorrectly recalledthattheweeklysurveillance sectionoftheprocedure hadbeencompleted andsignedofftheweeklysurveillance procedure ascomplete.

Following theperformance ofthesurveillances listedontheschedule, theOperations Department Engineering Sectionconductsareviewofthecompleted surveillance paperwork.

Duringthissurveillance paperwork review,theengineers identified on4-21-92thatthe1-OHP4030.STP.002V weeklysurveillance procedure sheetsweremissing.Upondiscovering thatNRCForm36SA(689)

)ACFORM3nSA(64)9)U.S.NUC(.EARREGULATORY COMMISSION LICENSEEEVEREPORT(LER)TEXTCONTINUATION APPROVEQ0MBNO.31500104EXPIRES:4/30/92ESATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REOUESTI500HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(PJ)301.U.S.NUCLEARREGULATORY COMMISSION.

WASHINGTON, DC20555,ANDTO1'HEPAPERWORK REDUCTION PROJECT(3(500(041, OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON.

DC20503..FACILITYNAME(1)DOCKETNUMBER(2)LERNUMBER(6)YEAR'julSEQUENTIAL,g>I(g REVISIONNUMBSR'..:MUAISSRPAGE(3ID.C.CookNuclearPlant-Unit1TEXT///moreepeoeLsJe)rrie(L oee~NRCForrlr36SA'4)l)7)31592-004-00P30Fptheweeklysurveillance procedure sheetsweremissing,theengineers documented thattheweeklysurveillance procedure wasingracebyrecording thestatusinthegracesectionoftheSurveillance StatusSummaryReport.Althoughtheengineers identified thattheweeklysurveillance wasapparently ingraceduetothemissingpaperwork, theengineers didnotpursuefurtherwhythesurveillance procedure hadnotbeencompleted.

Thiswasbasedontheengineers'ast experience hadshownthatthecontrolroomoperators alsotrackincomplete surveillances andpursuethecompletion ofasurveillance beforethegraceperiodexpires.CauseofEventThecauseforthemissedsurveillance waspersonnel error.TheUnitSupervisor developed amindsetduringthesurveillance reviewthatthesurveillance wascompleted andtherefore signedoffthesurveillance procedure ascompleteontheschedule.

Inaddition, theengineers hadamindsetthatcontrolroomoperators recordandtracksurveillances ingraceandthatthecontrolroomoperators wereawarethatthesurveillance hadnotbeencompleted, orthatthepaperwork musthavebeenroutedtotheengineers andhadnotarrived.Therefore, theengineers didnotpursuefurtherthecompletion ofthesurveillance.

A~nalslsTechnical Specification (TS)4.1.2.2.a.l (Reactivity ControlSystemsFlowPaths-Operating) requiresatleastoncepersevendaystheborationflowpathsfromtherefueling waterstoragetank(RWST)andtheboricacidstoragetank(BAST)tobeprovenoperablebycyclingeachtestablepower-operated orautomatic valveintheflowpaththroughatleaseonecompletecycleoffulltravel.Thefailuretoperformthesurveillance isaviolation ofTechnical Specification 3.1.2.2andisreportable under10CFR50.73(a)(2)(i)(B).

Following theidentification ofthemissedsurveillance, the1-OHP4030.STP.002V surveillance procedure wasperformed tosatisfytherequirements ofTS4.1.2.2.a.l.

Areviewofthecompleted surveillance notedthattherequirements ofthesurveillance procedure weremet.Therefore, itisconcluded thatthevalvestestedbythesurveillance procedure wouldhaveperformed theirsafetyfunctionifrequiredduringthetimeperiodfromthelastcompleted surveillance procedure on4-13-92andthesurveillance procedure performed on4-24-92.NR0Form366A(6419)

I/RCFOR)4A(64)9)V.S.NUCLEARREGULATORY COMMISSION LICENSEEEVEREPORT(LER)TEXTCONTINUATION APPAOVEDOMBNO.31500104EXP)RES:4/30/92ESiATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:508)HAS.FORWARDCOMMENTSREGARDING BURDENESTIMATETQTH'ERECORDSANDREPORTSMANAGEMENT BRANCH(PB30).V.S.NUCLEARREGULATORY COMMISSION.

WASHINGTON.

OC20555.ANDTO1MEPAPERWORK AEDUCTION PAO/ECT(315041041.

OFFICEOFMANAGEMENT ANOBUDGET,WASHINGTON.

DC20503.FACILITYNAMEI1)DOCKETNUMBER(2)LERNUMBER(6)PAGE(3)YEARPINSEQUENTIAL NUMBER<I'AREVISIONNUMBERD.C.CookNuclearPlant-Unit1TEXT//IIINeeepeeele/eeIeeN/Bee~////Bone/HRC Fem)366A'4)(17)315920040004OF04Basedupontheaboveanalysis, thefailuretoperformthesurveillance procedure withinthegraceperiodisnotconsidered tohavecreatedasignificant safetyconcern,nordidthemissedsurveillance createasignificant hazardtothehealthandsafetyofthegeneralpublic.Corrective Action1.Following theidentification thattheportionofthe1-OHP4030.STP.002V surveillance procedure hadnotbeenperformed, the1-OHP4030.STP.002V surveillance procedure wassatisfactorily completed.

TheShiftSupervisor reviewedThefindingofthisinvestigation withtheinvolvedUnitSupervisor.

Thisreviewincludedadiscussion oftheUnitSupervisor responsibility andaccountability fortheperformance anddocumentation ofsurveillance procedures.

TheOperations Department Production Supervisor reviewedthefindingofthisinvestigation withtheengineers involved.

PreviousSimilaEventsAreviewoftheLicenseEventReportsdidnotidentifyasimilarevent.NRCFomI366A(64)9)

~~~/6 ACCELERATED DISRIBUTIONDEMONSTIONSYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESSION NBR:9205270001 DOC.DATE:

92/05/20NOTARIZED:

NODOCKETFACIL:50-315 DonaldC.CookNuclearPowerPlant,Unit1,IndianaM05000315AUTH.NAMEAUTHORAFFILIATION SAMPSON,J.R.

IndianaMichiganPowerCo.(formerly Indiana6MichiganEleBLIND,A.A.

IndianaMichiganPowerCo.(formerly Indiana6MichiganEleRECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER92-004-00:on 920420,7-day testtoproveoperability ofborationflowpathsfromrefueling waterstorage6boricacidstoragetanksnotperformed asscheduled.

Causedbypersonnel error.Testsuccessfully performed.W/920520 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR IENCLJSIZE:STITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:DRECIPIENT IDCODE/NAME PD3-1LASTANG,JINTERNAL'CNW AEOD/DSP/TPABNRR/DET/EMEB 7ENRR/DLPQ/LPEB10 NRR/DREP/PRPB11 NRR/DST/SICBSH3 NRR/DST/SRXB SERES/DSIR/EIB EXTERNALEGGGBRYCEgJ~HNRCPDRNSICPOOREgW~COPIESLTTRENCL11112211111122111111331111RECIPIENT IDCODE/NAME PD3-1PDAEOD/DOAAEOD/ROAB/DSP NRR/DLPQ/LHFB10 NRR/DOEA/OEAB NRR/DST/SELB SDNRRSDPLBSD1G~E02RGN3FILE01LSTLOBBYWARDNSICMURPHY,G.A NUDOCSFULLTXTCOPIESLTTRENCL111122111111111111111111DDDNOTETOALL"RIDS"RECIPIENTS:

PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELMINATEYOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!DDFULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:

LTTR30ENCL30 IndianaMichiganPowerCompanyCookNuclearPlant~OneCookPlaceBridgman, Ml491066164655901May20,1992INDUNANICMGAMPOPOVERUnitedStatesNuclearRegulatory Commission DocumentControlDeskRockville, Maryland20852Operating LicensesDPR-58DocketNo.50-315DocumentControlManager:Inaccordance withthecriteriaestablished by10CFR50.73entitledLicenseeEventReortSstemthefollowing reportisbeingsubmitted:

92-004-00 Sincerely, A.A.BlindPlantManager/sbAttachment c:D.H.Williams, Jr.A.B.Davis,RegionIIIE.E.Fitzpatrick P.A.BarrettB.F.Henderson R.F.KroegerB.Walters-Ft.WayneNRCResidentInspector J.F.Stang-NRCJ.G.KepplerM.R.PadgettG.Charnoff, Esq.D.HahnINPOS.J.Brewer/B.

P.LauzauB.A.Svensson920527000i 920520PDRADOCK05000315SPDR

NRCFORM346(64)9)FACILITYNAME(I)V.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)D.C.CookNuclearPlant-Unit1tAPPROVEDOMBNO.31504)104 EXPIRES:4I30192ESTIMATED BURDENPEARESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION AEOUESTt50.0HRS.FORWAADCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(PPr30),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31500104),

OFFICEOFMANAGEMENT ANDBUDGET)WASHINGTON, DC20503.DOCKETNUMBERl2)PAGE.3050003]51OF04TITLE(4)MissedSurveillance onBoricAcidFlowPathduetoPersonnel ErrorDuringProcedure ReviewProcessEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIES INVOLVED(4)MONTHOAYYEARYEARSEOVENTIAL opnNVMSEANVMSESIMONTHDAYYEARFACILITYNAMESDOCKETNUMBER(SI 05000042092920040005209205000OPERATING MODE(SljPOWERLEYEL899))Wv@~<20802(S)20.4061~)Ill(il20.405(eI(1l(ii)20.406(~)(1)(15)20AOS(el(1 l(ivt20.405(el(1) lvl20AOS(c)50.34(cl(1) 50.34(cl(2)

X60.73(~)(2)ill50,73(e)(2) liil50.73(e)(2((iil)

LICENSEECONTACTFORTHISLEA(12I50.73(e)(2)liv)50.73(~)(2)(vlS0,73(~)LEI(viil60.73(e)(2)(viii)(A)50.73(el(2)(viiil(BI 60.73(~I(2)(elTHISREPORTISSUBMITTED PURSUANTTOTHEREOUIREMENTS OF10CFRg:(Cn<<4onrormorroftnrIollowinPI (11)73.71(S)73.71(clDTHER(speedysnAostrrctOrlrvvrmlin Trit,NRCForm388AINAMEJ.R.Sampson,Operations Department TELEPHONE NUMBERAREACODE616465-5901 COMPLETEONELINEFOREACHCOMPONENT FAILUREDESCRIBED INTHISAEPOAT113)CAUSESYSTEMCOMPONENT MANUFAC.TVREREPORTABLE TONPADSaI(SI~BP; CAUSESYSTEMCOMPONENT MANUFAC-TIJRER~OP)BILn'(IQ<".4 SVPPLEMENTAL REPORTEXPECTED(14)EXPECTEDSUBMISSION DATE(15)klan%~'~MONTHDAYYEARYESllfyrs,complrtrEXPECTEDSIIEMISSIOII DATEJNOABsTRAcT(Limittof400sprees,Ir.,rppioxlmrtrlp liltrrnslnclrspreetvprwrittrnlinrsl(14)On4-20-92,contrarytoTechnical Specification (TS)4.1.2.2.a.l, theseven-day testtoprovetheoperability oftheborationflowpathsfromtherefueling waterstoragetankandtheboricacidstoragetankwasnotperformed asscheduled.

Thetestisaccomplished bycyclingeachtestablepower-operatedorautomatic

'valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillance wasidentified on4-24-92.Thesurveillance procedure wasimmediately performed.

Alltestacceptance criteriaweremet.Themissedsurveillance occurredasaresultofpersonnel errorduringthereviewprocess.Thefindingsofthiseventwerereviewedwiththeinvolvedpersonnel bytheirsupervisors.

NRCFosses346(64)9)

NRCFORM366A(64)9)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION tAPPROVEDOMBNO.31504104EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:50.0HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(P.530),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON.

DC20555,ANDTO1'HEPAPERWORK REDUCTION PROJECT(31500104),

OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(1)DOCKETNUMBER(2)YEARLERNUMBER(6)SEQUENTIAL NUMBERREVISIONNVMBERPAGE(3)D.C.CookNuclearPlant-Unit1TEXT///moro4O4co/4roqo/rod, IrJoodds/orM/HRC Form36649/(17)050003]590040002QF0Conditions PriortoOccurrence Unitone(U-1)inmodeoneat89.9Xpower.Unittwo(U-2)inmodesixatOXpower.DescritionofEventOn4-20-92,the1-OHP4030.STP.002V (Boration SystemValvePositionVerification andTesting)surveillance procedure wasnotperformed tosatisfytheTechnical Specification (TS)surveillance requirement 4.1.2.2.a.l forTS3.1.2.2(Reactivity ControlSystemsFlowPaths-Operation).

TS4.1.2.2.a.l requiresatleastoncepersevendaysthattheborationflowpathsfromtherefueling waterstoragetank(RWST)(EIIS/CB-TK) andtheboricacidstoragetank(BAST)(EIIS/CB-TK) beprovenoperablebycyclingeachtestablepower-operatedorautomatic valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillance procedure wasdiscovered byanOperations Department Engineeron4-24-92.Thesurveillance testwaslastperformed on4-13-92.TheTSactionstatement wasenteredat1255hoursandthe1-OHP4030.STP.002V surveillance procedure wasstarted,completed, andreviewedby1314hourson4-24-92.Areviewofthecompleted surveillance notedthatthesurveillance acceptance criteriaweresatisfied andtheactionstatement wasexitedatthistime.On4-20-92,theinvolvedUnitSupervisor (SeniorReactorOperator) reviewedthe1-OHP4030.STP.002V paperwork completed duringhisshift.Following thisreview,theUnitSupervisor recordedthecompleted sectionsofthe1-OHP4030.STP.002V surveillance procedure intheMasterSurveillance Schedule.

Whilerecording thecompleted sectionsofthesurveillance procedure justreviewed, theUnitSupervisor incorrectly recalledthattheweeklysurveillance sectionoftheprocedure hadbeencompleted andsignedofftheweeklysurveillance procedure ascomplete.

Following theperformance ofthesurveillances listedontheschedule, theOperations Department Engineering Sectionconductsareviewofthecompleted surveillance paperwork.

Duringthissurveillance paperwork review,theengineers identified on4-21-92thatthe1-OHP4030.STP.002V weeklysurveillance procedure sheetsweremissing.Upondiscovering thatNRCForm366A(64)9)

NRCFORM366A(64)9)UILNUCLEARREGULATORY COMMISSION LICENSEEEVENEPORT(LER)TEXTCONTINUATION APPROVEDOMBNO.31500104EXPIRESI4/30/92ESTIEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:50.0HAS,FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(P-530).V.S.NVCI.EARREGULATORY COMMISSION, WASHINGTON.

DC20555,ANDTO1'HEPAPERWORK REDUCTION PROJECT(31500104),

OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(1)DOCKETNUMBER(2)YEARLERNUMBER(6)SEOVENTIAL NUMSERREVISIONNUMBERPAGE(3)D.C.CookNuclearPlant-Unit1TEXT/l/moroEpoco/1rorlur)od, urooddldooo/

NRCForm36649/07)050003]5920040003QF0theweeklysurveillance procedure sheetsweremissing,theengineers documented thattheweeklysurveillance procedure wasingracebyrecording thestatusinthegracesectionoftheSurveillance StatusSummaryReport.Althoughtheengineers identified thattheweeklysurveillance wasapparently ingraceduetothemissingpaperwork, theengineers didnotpursuefurtherwhythesurveillance procedure hadnotbeencompleted.

Thiswasbasedontheengineers'ast experience hadshownthatthecontrolroomoperators alsotrackincomplete surveillances andpursuethecompletion ofasurveillance beforethegraceperiodexpires.CauseofEventThecauseforthemissedsurveillance waspersonnel error.TheUnitSupervisor developed amindsetduringthesurveillance reviewthatthesurveillance wascompleted andtherefore signedoffthesurveillance procedure ascompleteontheschedule.

Inaddition, theengineers hadamindsetthatcontrolroomoperators recordandtracksurveillances ingraceandthatthecontrolroomoperators wereawarethatthesurveillance hadnotbeencompleted, orthatthepaperwork musthavebeenroutedtotheengineers andhadnotarrived.Therefore, theengineers didnotpursuefurtherthecompletion ofthesurveillance.

A~nalsisTechnical Specification (TS)4.1.2.2.a.l (Reactivity ControlSystemsFlowPaths-Operating) requiresatleastoncepersevendaystheborationflowpathsfromtherefueling waterstoragetank(RWST)andtheboricacidstoragetank(BAST)tobeprovenoperablebycyclingeachtestablepower-operated orautomatic valveintheflowpaththroughatleastonecompletecycleoffulltravel.Thefailuretoperformthesurveillance isaviolation ofTechnical Specification 3.1.2.2andisreportable under10CFR50s73(a)(2)(i)(B).

Following theidentification ofthemissedsurveillance, the1-OHP4030.STP.002V surveillance procedure wasperformed tosatisfytherequirements ofTS4.1.2.2.a.l.

Areviewofthecompleted surveillance notedthattherequirements ofthesurveillance procedure weremet.Therefore, itisconcluded thatthevalvestestedbythesurveillance procedure wouldhaveperformed theirsafetyfunctionifrequiredduringthetimeperiodfromthelastcompleted surveillance procedure on4-13-92andthesurveillance procedure performed on4-24-92.NACForm366A(84)9)

NRCFORM366A(64)9)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENEPORT(LER)TEXTCONTINUATION APPROVEDOMBNO.31504(04EXPIRESI4/30/02ESTIFDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:500HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(P430),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31500104),

OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(1)~DOCKETNUMBER(2)LERNUMBER(6)PAGE(3)D.C.CookNuclearPlant-Unit1TEXTNmorttrrtctisttqur)td, u>>4ddrrr'ootr HRCForm3664'tll)7)YEAR31592SEQUENTIAI.

NUMBER0045+(REVISIONNUMBER00040F0Basedupontheaboveanalysis, thefailuretoperformthesurveillance procedure withinthegraceperiodisnotconsidered tohavecreatedasignificant safetyconcern,nordidthemissedsurveillance createasignificant hazardtothehealthandsafetyofthegeneralpublic.Corrective ActionFollowing theidentification thattheportionofthe1-OHP4030.STP.002V surveillance procedure hadnotbeenperformed, the1-OHP4030~STP.002Vsurveillance procedure wassatisfactorily completed.

2.TheShiftSupervisor reviewedThefindingofthisinvestigation withtheinvolvedUnitSupervisor.

Thisreviewincludedadiscussion oftheUnitSupervisor responsibility andaccountability fortheperformance anddocumentation ofsurveillance procedures.

3.TheOperations Department Production Supervisor, reviewedthefindingofthis.investigation withtheengineers involved.

PreviousSimilarEventsAreviewoftheLicenseEventReportsdidnotidentifyasimilarevent.NRCForm366A(64)B)

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