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{{#Wiki_filter:1!ndianaMichiganPowerCompanyCookNuc!earP!ant".neCookPlaceBridgman.
{{#Wiki_filter:1!ndiana Michigan Power Company Cook Nuc!ear P!ant".ne Cook Place Bridgman.Ml~9106 616 465 5901 May 20, 1992 diag INDIAN JL NlCHlG4N POWER United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-58 Docket No.50-315 Document Control Manager: ln accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ort S stem the following report is being submitted:
Ml~91066164655901May20,1992diagINDIANJLNlCHlG4NPOWERUnitedStatesNuclearRegulatory Commission DocumentControlDeskRockville, Maryland20852Operating LicensesDPR-58DocketNo.50-315DocumentControlManager:lnaccordance withthecriteriaestablished by10CFR50.73entitledLicenseeEventReortSstemthefollowing reportisbeingsubmitted:
92-004-00 Sincerely, A.A.Blind Plant Manager/sb Attachment c D.H.Williams, Jr.tA.B..Davis., Region~?Q'.E.Fitzpatrick P.A.Barrett B.F.Henderson , R.F.Kroeger B.Walters-Ft.Wayne NRC Resident Inspector J.F.Stang-NRC J.G.Keppler M.R.Padgett G.Charnoff, Escr.D.Hahn XNPO S.J.Brewer/B.P.Lauzau B.A.Svensson Q'c Oyga gAN g 61SR NRC FORM 366 (649)FACILITY NAME lll V S.NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)D.C.Cook Nuclear Plant-Unit 1 APPROVED 0MB NO.3150410C EXPIRES: C/30I92 ESTIMATED BURDEN PER RESPONSE TO COLIPLY WTH THIS INFORMATION COLLECTION REOUEST.500 HRS.FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMFNT BRANCH (F630), U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON.
92-004-00 Sincerely, A.A.BlindPlantManager/sbAttachment cD.H.Williams, Jr.tA.B..Davis.,Region~?Q'.E.Fitzpatrick P.A.BarrettB.F.Henderson
DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31$0C)10el.OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON.
,R.F.KroegerB.Walters-Ft.WayneNRCResidentInspector J.F.Stang-NRCJ.G.KepplerM.R.PadgettG.Charnoff, Escr.D.HahnXNPOS.J.Brewer/B.
DC 20503.DOCKET NUMBER (2)PA E 3 0 5 0 0 0 3 1 5 1 OF 0 4 TITLE Icl EVENT OATK (5)Missed Surveillance on Boric Acid Flow Path due to Personnel Error During Procedure Review Process REPORT DATE (7)OTHER FACILITIES INVOLVED (4)LER NUMBER LSI MONTH OAY YEAR YEAR SEOVENTIAL NVMSEII NVMSEII REVOKE MON)'H OAY YEAR FACILITY NAMES DOCKET NUMBFR(SI 0 5 0 0 0 04209292 0 0 4 0 0 0 5 2 0 9 2 0 5 0 0 0 OPERATING MODE (4)POWER LEYEL, 8 9 9 cR~'ro"'C V)O;r.carr.@20A02(SI 20A05(e)()Ill)20A054)(1l(EI 20AOS(e)(I)(IIII 20A05 4)(1)tlrl 20.4054)(1 I (rl 20AOS(cl 50M(el)1)50.34(c)(2) 50.73(e)(2) lll 60 7 34)l2)(9)50.73 Iel(2)(lli)
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.
LICENSEE CONTACT FOR THIS LER (12)50.73(el(2IGrl 60.73(el(2)(r I 50.7 3 4l(2Hrii)60.73(e)12)(rill)I Al 50.73 4 I (2 I 4lil)I 5 I 50,7S(~)IS)(el 0 THE R SOU(A EMENTS OF 10 C FR (): IC>rrCC Onr Or mrrr Of tnr fOIIOwinpl (11 THIS REPORT IS SUBMITTED PURSUANT T 73.71(SI 73.7((c)OTHER ISorc>fy>n Aottrrct Oelow rnrf In Fret, HAC Form SSSA>NAME J.R.Sampson, Operations Department TELEPHONE NUMBER AREA CODE 616465-5901 COMPLETE ON!LINE FOR EACH COIAPONENT FAILURE DESCRIBED IH THIS REPORT IIS)CAUSE SYSTEM COMPONENT MANUFAC.TUAER FPOATABLF.
DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31$0C)10el.OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON.
TO NPAOS CAUSE SYSTEM~~Xo..r;rl COMPONENT MANUFAC.TUREA EPOATABL TO NPAOS k~m c@o~5SUPPLEMENTAL REPORT EXPECTED IICI YES llf yrt, compirtr EXPECPEI>SVSMISSION DATEI NO ABSTRACT l(,lmit to tc00 torcrL I r., rpproelmrtrly lilrrrn tinplr tprtr tyPrwnttrn linwl l14)EXPECTED SUBMISSION DATE (15)MONTH DAY YEAR On 4-20-92, contrary to Technical Specification (TS)4.1.2.2.a.l, the seven-day test to prove the operability of the boration flow paths from the refueling water storage tank and the boric acid storage tank was not performed as scheduled.
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)
The test is accomplished by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.The missed surveillance was identified on 4-24-92.The surveillance procedure was immediately performed.
LICENSEECONTACTFORTHISLER(12)50.73(el(2IGrl 60.73(el(2)
All test acceptance criteria were met.The missed surveillance occurred as a result of personnel error during the review process.The findings of this event were reviewed with the involved personnel by their supervisors.
(rI50.734l(2Hrii) 60.73(e)12)
NRC Form 344 (649)
(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.
NRC FORM 3rrSA (689)U.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVE REPORT (LERI TEXT CONTINUATION t APPROVED OMB NOr 31504104 EXPIRES: rU30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 500 HRS.FORWARD COMMENTS RFGARDING BURDEN ESTIMATE TO THE RECORDS ANO REPORTS MANAGEMENT BRANCH (P430).U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, ANO TO 1NE PAPERWORK REDUCTION PROJECT (3)500104), OFFICE OF MANAGEMENT ANO BUDGET, WASHINGTON.
TONPAOSCAUSESYSTEM~~Xo..r;rlCOMPONENT MANUFAC.TUREAEPOATABLTONPAOSk~mc@o~5SUPPLEMENTAL REPORTEXPECTEDIICIYESllfyrt,compirtrEXPECPEI>
DC 20503.FACILITY NAME (1)DOCKET NUMBKR (2)LER NUMBER (Sl PAGE (3)YEAR II SKDUKNTIAL;~
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.
NUMSSR REVISION NVMISII D.C.Cook Nuclear Plant-Unit 1 TEXT (If more speceis rer)rrirer(Iree aAiiriorrei iVRC Form JSSAK)(IT)3 1 5 9 2 0 0 4-0 0 0 2 OF 0 4 Conditions Prior to Occurrence Unit one (U-1)in mode one at 89.9X power.Unit two (U-2)in mode six at OX power.Descri tion of Event On 4-20-92, the 1-OHP 4030.STP.002V (Boration System Valve Position Verification and Testing)surveillance procedure was not performed to satisfy the Technical Specification (TS)surveillance requirement 4.1.2.2.a.l for TS 3.1.2.2 (Reactivity Control Systems Flow Paths-Operation).
Thetestisaccomplished bycyclingeachtestablepower-operatedorautomatic valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillance wasidentified on4-24-92.Thesurveillance procedure wasimmediately performed.
TS 4.1.2.2.a.l requires at least once per seven days that the boration flow paths from the refueling water storage tank (RWST)(EIIS/CB-TK) and the boric acid storage tank (BAST)(EIIS/CB-TK) be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.The missed surveillance procedure was discovered by an Operations Department Engineer on 4-24-92, The surveillance test was last performed on 4-13-92.The TS action statement was entered at 1255 hours and the 1-OHP 4030.STP.002V surveillance procedure was started, completed, and reviewed by 1314 hours on 4-24-92.A review of the completed surveillance noted that the surveillance acceptance criteria were satisfied and the action statement was exited at this time.On 4-20-92, the involved Unit Supervisor (Senior Reactor Operator)reviewed the 1-OHP 4030.STP.002V paperwork completed during his shift.Following this review, the Unit Supervisor recorded the completed sections of the 1-OHP 4030.STP.002V surveillance procedure in the Master Surveillance Schedule.While recording the completed sections of the surveillance procedure just reviewed, the Unit Supervisor incorrectly recalled that the weekly surveillance section of the procedure had been completed and signed off the weekly surveillance procedure as complete.Following the performance of the surveillances listed on the schedule, the Operations Department Engineering Section conducts a review of the completed surveillance paperwork.
Alltestacceptance criteriaweremet.Themissedsurveillance occurredasaresultofpersonnel errorduringthereviewprocess.Thefindingsofthiseventwerereviewedwiththeinvolvedpersonnel bytheirsupervisors.
During this surveillance paperwork review, the engineers identified on 4-21-92 that the 1-OHP 4030.STP.002V weekly surveillance procedure sheets were missing.Upon discovering that NRC Form 36SA (689)  
NRCForm344(649)
)AC FORM 3nSA (64)9)U.S.NUC(.EAR REGULATORY COMMISSION LICENSEE EVE REPORT (LER)TEXT CONTINUATION APPROVEQ 0MB NO.31500104 EXPIRES: 4/30/92 ES ATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REOUESTI 500 HRS.FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (PJ)301.U.S.NUCLEAR REGULATORY COMMISSION.
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),
WASHINGTON, DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (3(500(041, OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON.
OFFICEOFMANAGEMENT ANOBUDGET,WASHINGTON.
DC 20503..FACILITY NAME (1)DOCKET NUMBER (2)LER NUMBER (6)YEAR'jul SEQUENTIAL,g>I(g REVISION NUMBSR'..: MUAISSR PAGE (3I D.C.Cook Nuclear Plant-Unit 1 TEXT///more epeoe Ls Je)rrie(L oee~NRC Forrlr 36SA'4)l)7)3 1 5 9 2-0 0 4-0 0 P 30F p the weekly surveillance procedure sheets were missing, the engineers documented that the weekly surveillance procedure was in grace by recording the status in the grace section of the Surveillance Status Summary Report.Although the engineers identified that the weekly surveillance was apparently in grace due to the missing paperwork, the engineers did not pursue further why the surveillance procedure had not been completed.
DC20503.FACILITYNAME(1)DOCKETNUMBKR(2)LERNUMBER(SlPAGE(3)YEARIISKDUKNTIAL;~
This was based on the engineers'ast experience had shown that the control room operators also track incomplete surveillances and pursue the completion of a surveillance before the grace period expires.Cause of Event The cause for the missed surveillance was personnel error.The Unit Supervisor developed a mind set during the surveillance review that the surveillance was completed and therefore signed off the surveillance procedure as complete on the schedule.In addition, the engineers had a mind set that control room operators record and track surveillances in grace and that the control room operators were aware that the surveillance had not been completed, or that the paperwork must have been routed to the engineers and had not arrived.Therefore, the engineers did not pursue further the completion of the surveillance.
NUMSSRREVISIONNVMISIID.C.CookNuclearPlant-Unit1TEXT(Ifmorespeceisrer)rrirer(
A~nal sls Technical Specification (TS)4.1.2.2.a.l (Reactivity Control Systems Flow Paths-Operating) requires at least once per seven days the boration flow paths from the refueling water storage tank (RWST)and the boric acid storage tank (BAST)to be proven operable by cycling each testable power-operated or automatic valve in the flow path through at lease one complete cycle of full travel.The failure to perform the surveillance is a violation of Technical Specification 3.1.2.2 and is reportable under 10 CFR 50.73 (a)(2)(i)(B).
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).
Following the identification of the missed surveillance, the 1-OHP 4030.STP.002V surveillance procedure was performed to satisfy the requirements of TS 4.1.2.2.a.l.
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.
A review of the completed surveillance noted that the requirements of the surveillance procedure were met.Therefore, it is concluded that the valves tested by the surveillance procedure would have performed their safety function if required during the time period from the last completed surveillance procedure on 4-13-92 and the surveillance procedure performed on 4-24-92.NR 0 Form 366A (6419)
Whilerecording thecompleted sectionsofthesurveillance procedure justreviewed, theUnitSupervisor incorrectly recalledthattheweeklysurveillance sectionoftheprocedure hadbeencompleted andsignedofftheweeklysurveillance procedure ascomplete.
I/RC FOR)4 A (64)9)V.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVE REPORT (LER)TEXT CONTINUATION APPAOVED OMB NO.31500104 EXP)RES: 4/30/92 ES i ATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 508)HAS.FORWARD COMMENTS REGARDING BURDEN ESTIMATE TQ TH'E RECORDS AND REPORTS MANAGEMENT BRANCH (PB30).V.S.NUCLEAR REGULATORY COMMISSION.
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.
WASHINGTON.
OC20555.ANDTO1MEPAPERWORK AEDUCTION PAO/ECT(315041041.
OC 20555.AND TO 1ME PAPERWORK AEDUCTION PAO/ECT (315041041.
OFFICEOFMANAGEMENT ANOBUDGET,WASHINGTON.
OFFICE OF MANAGEMENT ANO BUDGET, 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.
DC 20503.FACILITY NAME I 1)DOCKET NUMBER (2)LER NUMBER (6)PAGE (3)YEAR PIN SEQUENTIAL NUMBER<I'A REVISION NUMBER D.C.Cook Nuclear Plant-Unit 1 TEXT//I IINee epeee le/eeIeeN/Bee~////Bone/HRC Fem)366A'4)(17)3 1 5 9 2 0 0 4 0 0 0 4 OF 0 4 Based upon the above analysis, the failure to perform the surveillance procedure within the grace period is not considered to have created a significant safety concern, nor did the missed surveillance create a significant hazard to the health and safety of the general public.Corrective Action 1.Following the identification that the portion of the 1-OHP 4030.STP.002V surveillance procedure had not been performed, the 1-OHP 4030.STP.002V surveillance procedure was satisfactorily completed.
TheShiftSupervisor reviewedThefindingofthisinvestigation withtheinvolvedUnitSupervisor.
The Shift Supervisor reviewed The finding of this investigation with the involved Unit Supervisor.
Thisreviewincludedadiscussion oftheUnitSupervisor responsibility andaccountability fortheperformance anddocumentation ofsurveillance procedures.
This review included a discussion of the Unit Supervisor responsibility and accountability for the performance and documentation of surveillance procedures.
TheOperations Department Production Supervisor reviewedthefindingofthisinvestigation withtheengineers involved.
The Operations Department Production Supervisor reviewed the finding of this investigation with the engineers involved.Previous Simila Events A review of the License Event Reports did not identify a similar event.NRC FomI 366A (64)9)  
PreviousSimilaEventsAreviewoftheLicenseEventReportsdidnotidentifyasimilarevent.NRCFomI366A(64)9)  
~~~/6 ACCELERATED DIS RIBUTION DEMONS TION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)ACCESSION NBR:9205270001 DOC.DATE: 92/05/20 NOTARIZED:
~~~/6 ACCELERATED DISRIBUTIONDEMONSTIONSYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESSION NBR:9205270001 DOC.DATE:
NO DOCKET FACIL:50-315 Donald C.Cook Nuclear Power Plant, Unit 1, Indiana M 05000315 AUTH.NAME AUTHOR AFFILIATION SAMPSON,J.R.
92/05/20NOTARIZED:
Indiana Michigan Power Co.(formerly Indiana 6 Michigan Ele BLIND,A.A.
NODOCKETFACIL:50-315 DonaldC.CookNuclearPowerPlant,Unit1,IndianaM05000315AUTH.NAMEAUTHORAFFILIATION SAMPSON,J.R.
Indiana Michigan Power Co.(formerly Indiana 6 Michigan Ele RECIP.NAME RECIPIENT AFFILIATION
IndianaMichiganPowerCo.(formerly Indiana6MichiganEleBLIND,A.A.
IndianaMichiganPowerCo.(formerly Indiana6MichiganEleRECIP.NAME RECIPIENT AFFILIATION


==SUBJECT:==
==SUBJECT:==
LER92-004-00:on 920420,7-day testtoproveoperability ofborationflowpathsfromrefueling waterstorage6boricacidstoragetanksnotperformed asscheduled.
LER 92-004-00:on 920420,7-day test to prove operability of boration flow paths from refueling water storage 6 boric acid storage tanks not performed as scheduled.
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:
Caused by personnel error.Test successfully performed.W/920520 ltr.DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR I ENCL J SIZE: S TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.NOTES: D RECIPIENT ID CODE/NAME PD3-1 LA STANG,J INTERNAL'CNW AEOD/DS P/TPAB NRR/DET/EMEB 7E NRR/DLPQ/LPEB10 NRR/DREP/PRPB11 NRR/DST/SICBSH3 NRR/DST/SRXB SE RES/DSIR/EIB EXTERNAL EGGG BRYCE g J~H NRC PDR NSIC POOREgW~COPIES LTTR ENCL 1 1 1 1 2 2 1 1 1 1 1 1 2 2 1 1 1 1 1 1 3 3 1 1 1 1 RECIPIENT ID CODE/NAME PD3-1 PD AEOD/DOA AEOD/ROAB/DSP NRR/DLPQ/LHFB10 NRR/DOEA/OEAB NRR/DST/SELB SD NRR S DPLBSD1 G~E 02 RGN3 F I LE 0 1 L ST LOBBY WARD NSIC MURPHY,G.A NUDOCS FULL TXT COPIES LTTR ENCL 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 D D D NOTE TO ALL"RIDS" RECIPIENTS:
PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELMINATEYOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!DDFULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:
PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.20079)TO ELMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!D D FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 30 ENCL 30 Indiana Michigan Power Company Cook Nuclear Plant~One Cook Place Bridgman, Ml 49106 616 465 5901 May 20, 1992 INDUNA NICMGAM POPOVER United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-58 Docket No.50-315 Document Control Manager: In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ort S stem the following report is being submitted:
LTTR30ENCL30 IndianaMichiganPowerCompanyCookNuclearPlant~OneCookPlaceBridgman, Ml491066164655901May20,1992INDUNANICMGAMPOPOVERUnitedStatesNuclearRegulatory Commission DocumentControlDeskRockville, Maryland20852Operating LicensesDPR-58DocketNo.50-315DocumentControlManager:Inaccordance withthecriteriaestablished by10CFR50.73entitledLicenseeEventReortSstemthefollowing reportisbeingsubmitted:
92-004-00 Sincerely, A.A.Blind Plant Manager/sb Attachment c: D.H.Williams, Jr.A.B.Davis, Region III E.E.Fitzpatrick P.A.Barrett B.F.Henderson R.F.Kroeger B.Walters-Ft.Wayne NRC Resident Inspector J.F.Stang-NRC J.G.Keppler M.R.Padgett G.Charnoff, Esq.D.Hahn INPO S.J.Brewer/B.P.Lauzau B.A.Svensson 920527000i 920520 PDR ADOCK 05000315 S PDR
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),
NRC FORM 346 (64)9)FACILITY NAME (I)V.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)D.C.Cook Nuclear Plant-Unit 1 t APPROVED OMB NO.31504)104 EXPIRES: 4I30192 ESTIMATED BURDEN PEA RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION AEOUESTt 50.0 HRS.FORWAAD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (PPr30), U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENT AND BUDGET)WASHINGTON, DC 20503.DOCKET NUMBER l2)PAGE.3 0 5 0 0 0 3]5 1 OF 0 4 TITLE (4)Missed Surveillance on Boric Acid Flow Path due to Personnel Error During Procedure Review Process EVENT DATE(5)LER NUMBER (6)REPORT DATE (7)OTHER FACILITIES INVOLVED (4)MONTH OAY YEAR YEAR SEOVENTIAL opn NVMSEA NVMSESI MONTH DAY YEAR FACILITY NAMES DOCKET NUMBER(SI 0 5 0 0 0 0 4 2 0 9 2 9 2 0 0 4 0 0 0 5 2 0 9 2 0 5 0 0 0 OPERATING MODE (Sl j POWE R LEYEL 8 9 9))Wv@~<20802(S)20.4061~)Ill(il 20.405(e I (1 l(ii)20.406(~)(1)(15)20AOS(el(1 l(ivt 20.405(el(1) lvl 20AOS(c)50.34(cl(1) 50.34(cl(2)
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)
X 60.73(~)(2)ill 50,73(e)(2) liil 50.73(e)(2((iil)
X60.73(~)(2)ill50,73(e)(2) liil50.73(e)(2((iil)
LICENSEE CONTACT FOR THIS LEA (12I 50.73(e)(2)liv)50.73(~)(2)(vl S0,73(~)LE I(viil 60.73(e)(2)(viii)(A)50.73(el(2)(viiil(BI 60.73 (~I (2)(el THIS REPORT IS SUBMITTED PURSUANT TO THE REOUIREMENTS OF 10 CFR g: (Cn<<4 onr or morr of tnr IollowinPI (11)73.71(S)73.71(cl DTHER (speedy sn Aostrrct Orlrvvrmlin Trit, NRC Form 388AI NAME J.R.Sampson, Operations Department TELEPHONE NUMBER AREA CODE 616465-5901 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS AEPOAT 113)CAUSE SYSTEM COMPONENT MANUFAC.TVRER EPORTABLE TO NPADS aI(SI~BP;CAUSE SYSTEM COMPONENT MANUFAC-TIJRER~OP)BI Ln'(IQ<".4 SVPPLEMENTAL REPORT EXPECTED (14)EXPECTED SUBMISSION DATE (15)klan%~'~MONTH DAY YEAR YES llf yrs, complrtr EXPECTED SIIEMISSIOII DATEJ NO ABsTRAcT (Limit to f400 sprees, I r., rppioxlmrtrlp liltrrn slnclr spree tvprwri ttrn linrsl (14)On 4-20-92, contrary to Technical Specification (TS)4.1.2.2.a.l, the seven-day test to prove the operability of the boration flow paths from the refueling water storage tank and the boric acid storage tank was not performed as scheduled.
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.
The test is accomplished by cycling each testable power-operated or automatic'valve in the flow path through at least one complete cycle of full travel.The missed surveillance was identified on 4-24-92.The surveillance procedure was immediately performed.
Thetestisaccomplished bycyclingeachtestablepower-operatedorautomatic
All test acceptance criteria were met.The missed surveillance occurred as a result of personnel error during the review process.The findings of this event were reviewed with the involved personnel by their supervisors.
'valveintheflowpaththroughatleastonecompletecycleoffulltravel.Themissedsurveillance wasidentified on4-24-92.Thesurveillance procedure wasimmediately performed.
NRC Fosses 346 (64)9)
Alltestacceptance criteriaweremet.Themissedsurveillance occurredasaresultofpersonnel errorduringthereviewprocess.Thefindingsofthiseventwerereviewedwiththeinvolvedpersonnel bytheirsupervisors.
NRC FORM 366A (64)9)U.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)TEXT CONTINUATION t APPROVED OMB NO.31504104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P.530), U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON.
NRCFosses346(64)9)
DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.FACILITY NAME (1)DOCKET NUMBER (2)YEAR LER NUMBER (6)SEQUENTIAL NUMBER REVISION NVMBER PAGE (3)D.C.Cook Nuclear Plant-Unit 1 TEXT///moro 4O4co/4 roqo/rod, Ir Jo odds/orM/HRC Form 36649/(17)0 5 0 0 0 3]5 9 0 0 4 0 0 0 2 QF 0 Conditions Prior to Occurrence Unit one (U-1)in mode one at 89.9X power.Unit two (U-2)in mode six at OX power.Descri tion of Event On 4-20-92, the 1-OHP 4030.STP.002V (Boration System Valve Position Verification and Testing)surveillance procedure was not performed to satisfy the Technical Specification (TS)surveillance requirement 4.1.2.2.a.l for TS 3.1.2.2 (Reactivity Control Systems Flow Paths-Operation).
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.
TS 4.1.2.2.a.l requires at least once per seven days that the boration flow paths from the refueling water storage tank (RWST)(EIIS/CB-TK) and the boric acid storage tank (BAST)(EIIS/CB-TK) be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.The missed surveillance procedure was discovered by an Operations Department Engineer on 4-24-92.The surveillance test was last performed on 4-13-92.The TS action statement was entered at 1255 hours and the 1-OHP 4030.STP.002V surveillance procedure was started, completed, and reviewed by 1314 hours on 4-24-92.A review of the completed surveillance noted that the surveillance acceptance criteria were satisfied and the action statement was exited at this time.On 4-20-92, the involved Unit Supervisor (Senior Reactor Operator)reviewed the 1-OHP 4030.STP.002V paperwork completed during his shift.Following this review, the Unit Supervisor recorded the completed sections of the 1-OHP 4030.STP.002V surveillance procedure in the Master Surveillance Schedule.While recording the completed sections of the surveillance procedure just reviewed, the Unit Supervisor incorrectly recalled that the weekly surveillance section of the procedure had been completed and signed off the weekly surveillance procedure as complete.Following the performance of the surveillances listed on the schedule, the Operations Department Engineering Section conducts a review of the completed surveillance paperwork.
DC20555,ANDTO1'HEPAPERWORK REDUCTION PROJECT(31500104),
During this surveillance paperwork review, the engineers identified on 4-21-92 that the 1-OHP 4030.STP.002V weekly surveillance procedure sheets were missing.Upon discovering that NR C Form 366A (64)9)
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).
NRC FORM 366A (64)9)U IL NUCLEAR REGULATORY COMMISSION LICENSEE EVEN EPORT (LER)TEXT CONTINUATION APPROVED OMB NO.31500104 EXPIRESI 4/30/92 ESTI ED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HAS, FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P-530).V.S.NVCI.EAR REGULATORY COMMISSION, WASHINGTON.
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.
DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.FACILITY NAME (1)DOCKET NUMBER (2)YEAR LER NUMBER (6)SEOVENTIAL NUMSER REVISION NUMBER PAGE (3)D.C.Cook Nuclear Plant-Unit 1 TEXT/l/moro Epoco/1 rorlur)od, uro oddldooo/NRC Form 3664 9/07)0 5 0 0 0 3]5 9 2 0 0 4 0 0 0 3 QF 0 the weekly surveillance procedure sheets were missing, the engineers documented that the weekly surveillance procedure was in grace by recording the status in the grace section of the Surveillance Status Summary Report.Although the engineers identified that the weekly surveillance was apparently in grace due to the missing paperwork, the engineers did not pursue further why the surveillance procedure had not been completed.
Whilerecording thecompleted sectionsofthesurveillance procedure justreviewed, theUnitSupervisor incorrectly recalledthattheweeklysurveillance sectionoftheprocedure hadbeencompleted andsignedofftheweeklysurveillance procedure ascomplete.
This was based on the engineers'ast experience had shown that the control room operators also track incomplete surveillances and pursue the completion of a surveillance before the grace period expires.Cause of Event The cause for the missed surveillance was personnel error.The Unit Supervisor developed a mind set during the surveillance review that the surveillance was completed and therefore signed off the surveillance procedure as complete on the schedule.In addition, the engineers had a mind set that control room operators record and track surveillances in grace and that the control room operators were aware that the surveillance had not been completed, or that the paperwork must have been routed to the engineers and had not arrived.Therefore, the engineers did not pursue further the completion of the surveillance.
Following theperformance ofthesurveillances listedontheschedule, theOperations Department Engineering Sectionconductsareviewofthecompleted surveillance paperwork.
A~nal sis Technical Specification (TS)4.1.2.2.a.l (Reactivity Control Systems Flow Paths-Operating) requires at least once per seven days the boration flow paths from the refueling water storage tank (RWST)and the boric acid storage tank (BAST)to be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.The failure to perform the surveillance is a violation of Technical Specification 3.1.2.2 and is reportable under 10 CFR 50s73 (a)(2)(i)(B).
Duringthissurveillance paperwork review,theengineers identified on4-21-92thatthe1-OHP4030.STP.002V weeklysurveillance procedure sheetsweremissing.Upondiscovering thatNRCForm366A(64)9)
Following the identification of the missed surveillance, the 1-OHP 4030.STP.002V surveillance procedure was performed to satisfy the requirements of TS 4.1.2.2.a.l.
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.
A review of the completed surveillance noted that the requirements of the surveillance procedure were met.Therefore, it is concluded that the valves tested by the surveillance procedure would have performed their safety function if required during the time period from the last completed surveillance procedure on 4-13-92 and the surveillance procedure performed on 4-24-92.NAC Form 366A (84)9)
DC20555,ANDTO1'HEPAPERWORK REDUCTION PROJECT(31500104),
NRC FORM 366A (64)9)U.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVEN EPORT (LER)TEXT CONTINUATION APPROVED OMB NO.31504(04 EXPIRESI 4/30/02 ESTI FD BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 500 HRS.FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P430), U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.FACILITY NAME (1)~DOCKET NUMBER (2)LER NUMBER (6)PAGE (3)D.C.Cook Nuclear Plant-Unit 1 TEXT N mort trrtct is ttqur)td, u>>4ddrrr'ootr HRC Form 3664'tl l)7)YEAR 3 1 5 9 2 SEQUENTIAI.
OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(1)DOCKETNUMBER(2)YEARLERNUMBER(6)SEOVENTIAL NUMSERREVISIONNUMBERPAGE(3)D.C.CookNuclearPlant-Unit1TEXT/l/moroEpoco/1rorlur)od, urooddldooo/
NUMBER 0 0 4 5+(REVISION NUMBER 0 0 0 40F 0 Based upon the above analysis, the failure to perform the surveillance procedure within the grace period is not considered to have created a significant safety concern, nor did the missed surveillance create a significant hazard to the health and safety of the general public.Corrective Action Following the identification that the portion of the 1-OHP 4030.STP.002V surveillance procedure had not been performed, the 1-OHP 4030~STP.002V surveillance procedure was satisfactorily completed.
NRCForm36649/07)050003]5920040003QF0theweeklysurveillance procedure sheetsweremissing,theengineers documented thattheweeklysurveillance procedure wasingracebyrecording thestatusinthegracesectionoftheSurveillance StatusSummaryReport.Althoughtheengineers identified thattheweeklysurveillance wasapparently ingraceduetothemissingpaperwork, theengineers didnotpursuefurtherwhythesurveillance procedure hadnotbeencompleted.
2.The Shift Supervisor reviewed The finding of this investigation with the involved Unit Supervisor.
Thiswasbasedontheengineers'ast experience hadshownthatthecontrolroomoperators alsotrackincomplete surveillances andpursuethecompletion ofasurveillance beforethegraceperiodexpires.CauseofEventThecauseforthemissedsurveillance waspersonnel error.TheUnitSupervisor developed amindsetduringthesurveillance reviewthatthesurveillance wascompleted andtherefore signedoffthesurveillance procedure ascompleteontheschedule.
This review included a discussion of the Unit Supervisor responsibility and accountability for the performance and documentation of surveillance procedures.
Inaddition, theengineers hadamindsetthatcontrolroomoperators recordandtracksurveillances ingraceandthatthecontrolroomoperators wereawarethatthesurveillance hadnotbeencompleted, orthatthepaperwork musthavebeenroutedtotheengineers andhadnotarrived.Therefore, theengineers didnotpursuefurtherthecompletion ofthesurveillance.
3.The Operations Department Production Supervisor, reviewed the finding of this.investigation with the engineers involved.Previous Similar Events A review of the License Event Reports did not identify a similar event.NRC Form 366A (64)B)}}
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 08:42, 6 July 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)


Text

1!ndiana Michigan Power Company Cook Nuc!ear P!ant".ne Cook Place Bridgman.Ml~9106 616 465 5901 May 20, 1992 diag INDIAN JL NlCHlG4N POWER United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-58 Docket No.50-315 Document Control Manager: ln accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ort S stem the following report is being submitted:

92-004-00 Sincerely, A.A.Blind Plant Manager/sb Attachment c D.H.Williams, Jr.tA.B..Davis., Region~?Q'.E.Fitzpatrick P.A.Barrett B.F.Henderson , R.F.Kroeger B.Walters-Ft.Wayne NRC Resident Inspector J.F.Stang-NRC J.G.Keppler M.R.Padgett G.Charnoff, Escr.D.Hahn XNPO S.J.Brewer/B.P.Lauzau B.A.Svensson Q'c Oyga gAN g 61SR NRC FORM 366 (649)FACILITY NAME lll V S.NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)D.C.Cook Nuclear Plant-Unit 1 APPROVED 0MB NO.3150410C EXPIRES: C/30I92 ESTIMATED BURDEN PER RESPONSE TO COLIPLY WTH THIS INFORMATION COLLECTION REOUEST.500 HRS.FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMFNT BRANCH (F630), U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON.

DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31$0C)10el.OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON.

DC 20503.DOCKET NUMBER (2)PA E 3 0 5 0 0 0 3 1 5 1 OF 0 4 TITLE Icl EVENT OATK (5)Missed Surveillance on Boric Acid Flow Path due to Personnel Error During Procedure Review Process REPORT DATE (7)OTHER FACILITIES INVOLVED (4)LER NUMBER LSI MONTH OAY YEAR YEAR SEOVENTIAL NVMSEII NVMSEII REVOKE MON)'H OAY YEAR FACILITY NAMES DOCKET NUMBFR(SI 0 5 0 0 0 04209292 0 0 4 0 0 0 5 2 0 9 2 0 5 0 0 0 OPERATING MODE (4)POWER LEYEL, 8 9 9 cR~'ro"'C V)O;r.carr.@20A02(SI 20A05(e)()Ill)20A054)(1l(EI 20AOS(e)(I)(IIII 20A05 4)(1)tlrl 20.4054)(1 I (rl 20AOS(cl 50M(el)1)50.34(c)(2) 50.73(e)(2) lll 60 7 34)l2)(9)50.73 Iel(2)(lli)

LICENSEE CONTACT FOR THIS LER (12)50.73(el(2IGrl 60.73(el(2)(r I 50.7 3 4l(2Hrii)60.73(e)12)(rill)I Al 50.73 4 I (2 I 4lil)I 5 I 50,7S(~)IS)(el 0 THE R SOU(A EMENTS OF 10 C FR (): IC>rrCC Onr Or mrrr Of tnr fOIIOwinpl (11 THIS REPORT IS SUBMITTED PURSUANT T 73.71(SI 73.7((c)OTHER ISorc>fy>n Aottrrct Oelow rnrf In Fret, HAC Form SSSA>NAME J.R.Sampson, Operations Department TELEPHONE NUMBER AREA CODE 616465-5901 COMPLETE ON!LINE FOR EACH COIAPONENT FAILURE DESCRIBED IH THIS REPORT IIS)CAUSE SYSTEM COMPONENT MANUFAC.TUAER FPOATABLF.

TO NPAOS CAUSE SYSTEM~~Xo..r;rl COMPONENT MANUFAC.TUREA EPOATABL TO NPAOS k~m c@o~5SUPPLEMENTAL REPORT EXPECTED IICI YES llf yrt, compirtr EXPECPEI>SVSMISSION DATEI NO ABSTRACT l(,lmit to tc00 torcrL I r., rpproelmrtrly lilrrrn tinplr tprtr tyPrwnttrn linwl l14)EXPECTED SUBMISSION DATE (15)MONTH DAY YEAR On 4-20-92, contrary to Technical Specification (TS)4.1.2.2.a.l, the seven-day test to prove the operability of the boration flow paths from the refueling water storage tank and the boric acid storage tank was not performed as scheduled.

The test is accomplished by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.The missed surveillance was identified on 4-24-92.The surveillance procedure was immediately performed.

All test acceptance criteria were met.The missed surveillance occurred as a result of personnel error during the review process.The findings of this event were reviewed with the involved personnel by their supervisors.

NRC Form 344 (649)

NRC FORM 3rrSA (689)U.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVE REPORT (LERI TEXT CONTINUATION t APPROVED OMB NOr 31504104 EXPIRES: rU30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 500 HRS.FORWARD COMMENTS RFGARDING BURDEN ESTIMATE TO THE RECORDS ANO REPORTS MANAGEMENT BRANCH (P430).U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, ANO TO 1NE PAPERWORK REDUCTION PROJECT (3)500104), OFFICE OF MANAGEMENT ANO BUDGET, WASHINGTON.

DC 20503.FACILITY NAME (1)DOCKET NUMBKR (2)LER NUMBER (Sl PAGE (3)YEAR II SKDUKNTIAL;~

NUMSSR REVISION NVMISII D.C.Cook Nuclear Plant-Unit 1 TEXT (If more speceis rer)rrirer(Iree aAiiriorrei iVRC Form JSSAK)(IT)3 1 5 9 2 0 0 4-0 0 0 2 OF 0 4 Conditions Prior to Occurrence Unit one (U-1)in mode one at 89.9X power.Unit two (U-2)in mode six at OX power.Descri tion of Event On 4-20-92, the 1-OHP 4030.STP.002V (Boration System Valve Position Verification and Testing)surveillance procedure was not performed to satisfy the Technical Specification (TS)surveillance requirement 4.1.2.2.a.l for TS 3.1.2.2 (Reactivity Control Systems Flow Paths-Operation).

TS 4.1.2.2.a.l requires at least once per seven days that the boration flow paths from the refueling water storage tank (RWST)(EIIS/CB-TK) and the boric acid storage tank (BAST)(EIIS/CB-TK) be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.The missed surveillance procedure was discovered by an Operations Department Engineer on 4-24-92, The surveillance test was last performed on 4-13-92.The TS action statement was entered at 1255 hours0.0145 days <br />0.349 hours <br />0.00208 weeks <br />4.775275e-4 months <br /> and the 1-OHP 4030.STP.002V surveillance procedure was started, completed, and reviewed by 1314 hours0.0152 days <br />0.365 hours <br />0.00217 weeks <br />4.99977e-4 months <br /> on 4-24-92.A review of the completed surveillance noted that the surveillance acceptance criteria were satisfied and the action statement was exited at this time.On 4-20-92, the involved Unit Supervisor (Senior Reactor Operator)reviewed the 1-OHP 4030.STP.002V paperwork completed during his shift.Following this review, the Unit Supervisor recorded the completed sections of the 1-OHP 4030.STP.002V surveillance procedure in the Master Surveillance Schedule.While recording the completed sections of the surveillance procedure just reviewed, the Unit Supervisor incorrectly recalled that the weekly surveillance section of the procedure had been completed and signed off the weekly surveillance procedure as complete.Following the performance of the surveillances listed on the schedule, the Operations Department Engineering Section conducts a review of the completed surveillance paperwork.

During this surveillance paperwork review, the engineers identified on 4-21-92 that the 1-OHP 4030.STP.002V weekly surveillance procedure sheets were missing.Upon discovering that NRC Form 36SA (689)

)AC FORM 3nSA (64)9)U.S.NUC(.EAR REGULATORY COMMISSION LICENSEE EVE REPORT (LER)TEXT CONTINUATION APPROVEQ 0MB NO.31500104 EXPIRES: 4/30/92 ES ATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REOUESTI 500 HRS.FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (PJ)301.U.S.NUCLEAR REGULATORY COMMISSION.

WASHINGTON, DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (3(500(041, OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON.

DC 20503..FACILITY NAME (1)DOCKET NUMBER (2)LER NUMBER (6)YEAR'jul SEQUENTIAL,g>I(g REVISION NUMBSR'..: MUAISSR PAGE (3I D.C.Cook Nuclear Plant-Unit 1 TEXT///more epeoe Ls Je)rrie(L oee~NRC Forrlr 36SA'4)l)7)3 1 5 9 2-0 0 4-0 0 P 30F p the weekly surveillance procedure sheets were missing, the engineers documented that the weekly surveillance procedure was in grace by recording the status in the grace section of the Surveillance Status Summary Report.Although the engineers identified that the weekly surveillance was apparently in grace due to the missing paperwork, the engineers did not pursue further why the surveillance procedure had not been completed.

This was based on the engineers'ast experience had shown that the control room operators also track incomplete surveillances and pursue the completion of a surveillance before the grace period expires.Cause of Event The cause for the missed surveillance was personnel error.The Unit Supervisor developed a mind set during the surveillance review that the surveillance was completed and therefore signed off the surveillance procedure as complete on the schedule.In addition, the engineers had a mind set that control room operators record and track surveillances in grace and that the control room operators were aware that the surveillance had not been completed, or that the paperwork must have been routed to the engineers and had not arrived.Therefore, the engineers did not pursue further the completion of the surveillance.

A~nal sls Technical Specification (TS)4.1.2.2.a.l (Reactivity Control Systems Flow Paths-Operating) requires at least once per seven days the boration flow paths from the refueling water storage tank (RWST)and the boric acid storage tank (BAST)to be proven operable by cycling each testable power-operated or automatic valve in the flow path through at lease one complete cycle of full travel.The failure to perform the surveillance is a violation of Technical Specification 3.1.2.2 and is reportable under 10 CFR 50.73 (a)(2)(i)(B).

Following the identification of the missed surveillance, the 1-OHP 4030.STP.002V surveillance procedure was performed to satisfy the requirements of TS 4.1.2.2.a.l.

A review of the completed surveillance noted that the requirements of the surveillance procedure were met.Therefore, it is concluded that the valves tested by the surveillance procedure would have performed their safety function if required during the time period from the last completed surveillance procedure on 4-13-92 and the surveillance procedure performed on 4-24-92.NR 0 Form 366A (6419)

I/RC FOR)4 A (64)9)V.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVE REPORT (LER)TEXT CONTINUATION APPAOVED OMB NO.31500104 EXP)RES: 4/30/92 ES i ATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 508)HAS.FORWARD COMMENTS REGARDING BURDEN ESTIMATE TQ TH'E RECORDS AND REPORTS MANAGEMENT BRANCH (PB30).V.S.NUCLEAR REGULATORY COMMISSION.

WASHINGTON.

OC 20555.AND TO 1ME PAPERWORK AEDUCTION PAO/ECT (315041041.

OFFICE OF MANAGEMENT ANO BUDGET, WASHINGTON.

DC 20503.FACILITY NAME I 1)DOCKET NUMBER (2)LER NUMBER (6)PAGE (3)YEAR PIN SEQUENTIAL NUMBER<I'A REVISION NUMBER D.C.Cook Nuclear Plant-Unit 1 TEXT//I IINee epeee le/eeIeeN/Bee~////Bone/HRC Fem)366A'4)(17)3 1 5 9 2 0 0 4 0 0 0 4 OF 0 4 Based upon the above analysis, the failure to perform the surveillance procedure within the grace period is not considered to have created a significant safety concern, nor did the missed surveillance create a significant hazard to the health and safety of the general public.Corrective Action 1.Following the identification that the portion of the 1-OHP 4030.STP.002V surveillance procedure had not been performed, the 1-OHP 4030.STP.002V surveillance procedure was satisfactorily completed.

The Shift Supervisor reviewed The finding of this investigation with the involved Unit Supervisor.

This review included a discussion of the Unit Supervisor responsibility and accountability for the performance and documentation of surveillance procedures.

The Operations Department Production Supervisor reviewed the finding of this investigation with the engineers involved.Previous Simila Events A review of the License Event Reports did not identify a similar event.NRC FomI 366A (64)9)

~~~/6 ACCELERATED DIS RIBUTION DEMONS TION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)ACCESSION NBR:9205270001 DOC.DATE: 92/05/20 NOTARIZED:

NO DOCKET FACIL:50-315 Donald C.Cook Nuclear Power Plant, Unit 1, Indiana M 05000315 AUTH.NAME AUTHOR AFFILIATION SAMPSON,J.R.

Indiana Michigan Power Co.(formerly Indiana 6 Michigan Ele BLIND,A.A.

Indiana Michigan Power Co.(formerly Indiana 6 Michigan Ele RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 92-004-00:on 920420,7-day test to prove operability of boration flow paths from refueling water storage 6 boric acid storage tanks not performed as scheduled.

Caused by personnel error.Test successfully performed.W/920520 ltr.DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR I ENCL J SIZE: S TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.NOTES: D RECIPIENT ID CODE/NAME PD3-1 LA STANG,J INTERNAL'CNW AEOD/DS P/TPAB NRR/DET/EMEB 7E NRR/DLPQ/LPEB10 NRR/DREP/PRPB11 NRR/DST/SICBSH3 NRR/DST/SRXB SE RES/DSIR/EIB EXTERNAL EGGG BRYCE g J~H NRC PDR NSIC POOREgW~COPIES LTTR ENCL 1 1 1 1 2 2 1 1 1 1 1 1 2 2 1 1 1 1 1 1 3 3 1 1 1 1 RECIPIENT ID CODE/NAME PD3-1 PD AEOD/DOA AEOD/ROAB/DSP NRR/DLPQ/LHFB10 NRR/DOEA/OEAB NRR/DST/SELB SD NRR S DPLBSD1 G~E 02 RGN3 F I LE 0 1 L ST LOBBY WARD NSIC MURPHY,G.A NUDOCS FULL TXT COPIES LTTR ENCL 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 D D D NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.20079)TO ELMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!D D FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 30 ENCL 30 Indiana Michigan Power Company Cook Nuclear Plant~One Cook Place Bridgman, Ml 49106 616 465 5901 May 20, 1992 INDUNA NICMGAM POPOVER United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-58 Docket No.50-315 Document Control Manager: In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ort S stem the following report is being submitted:

92-004-00 Sincerely, A.A.Blind Plant Manager/sb Attachment c: D.H.Williams, Jr.A.B.Davis, Region III E.E.Fitzpatrick P.A.Barrett B.F.Henderson R.F.Kroeger B.Walters-Ft.Wayne NRC Resident Inspector J.F.Stang-NRC J.G.Keppler M.R.Padgett G.Charnoff, Esq.D.Hahn INPO S.J.Brewer/B.P.Lauzau B.A.Svensson 920527000i 920520 PDR ADOCK 05000315 S PDR

NRC FORM 346 (64)9)FACILITY NAME (I)V.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)D.C.Cook Nuclear Plant-Unit 1 t APPROVED OMB NO.31504)104 EXPIRES: 4I30192 ESTIMATED BURDEN PEA RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION AEOUESTt 50.0 HRS.FORWAAD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (PPr30), U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENT AND BUDGET)WASHINGTON, DC 20503.DOCKET NUMBER l2)PAGE.3 0 5 0 0 0 3]5 1 OF 0 4 TITLE (4)Missed Surveillance on Boric Acid Flow Path due to Personnel Error During Procedure Review Process EVENT DATE(5)LER NUMBER (6)REPORT DATE (7)OTHER FACILITIES INVOLVED (4)MONTH OAY YEAR YEAR SEOVENTIAL opn NVMSEA NVMSESI MONTH DAY YEAR FACILITY NAMES DOCKET NUMBER(SI 0 5 0 0 0 0 4 2 0 9 2 9 2 0 0 4 0 0 0 5 2 0 9 2 0 5 0 0 0 OPERATING MODE (Sl j POWE R LEYEL 8 9 9))Wv@~<20802(S)20.4061~)Ill(il 20.405(e I (1 l(ii)20.406(~)(1)(15)20AOS(el(1 l(ivt 20.405(el(1) lvl 20AOS(c)50.34(cl(1) 50.34(cl(2)

X 60.73(~)(2)ill 50,73(e)(2) liil 50.73(e)(2((iil)

LICENSEE CONTACT FOR THIS LEA (12I 50.73(e)(2)liv)50.73(~)(2)(vl S0,73(~)LE I(viil 60.73(e)(2)(viii)(A)50.73(el(2)(viiil(BI 60.73 (~I (2)(el THIS REPORT IS SUBMITTED PURSUANT TO THE REOUIREMENTS OF 10 CFR g: (Cn<<4 onr or morr of tnr IollowinPI (11)73.71(S)73.71(cl DTHER (speedy sn Aostrrct Orlrvvrmlin Trit, NRC Form 388AI NAME J.R.Sampson, Operations Department TELEPHONE NUMBER AREA CODE 616465-5901 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS AEPOAT 113)CAUSE SYSTEM COMPONENT MANUFAC.TVRER EPORTABLE TO NPADS aI(SI~BP;CAUSE SYSTEM COMPONENT MANUFAC-TIJRER~OP)BI Ln'(IQ<".4 SVPPLEMENTAL REPORT EXPECTED (14)EXPECTED SUBMISSION DATE (15)klan%~'~MONTH DAY YEAR YES llf yrs, complrtr EXPECTED SIIEMISSIOII DATEJ NO ABsTRAcT (Limit to f400 sprees, I r., rppioxlmrtrlp liltrrn slnclr spree tvprwri ttrn linrsl (14)On 4-20-92, contrary to Technical Specification (TS)4.1.2.2.a.l, the seven-day test to prove the operability of the boration flow paths from the refueling water storage tank and the boric acid storage tank was not performed as scheduled.

The test is accomplished by cycling each testable power-operated or automatic'valve in the flow path through at least one complete cycle of full travel.The missed surveillance was identified on 4-24-92.The surveillance procedure was immediately performed.

All test acceptance criteria were met.The missed surveillance occurred as a result of personnel error during the review process.The findings of this event were reviewed with the involved personnel by their supervisors.

NRC Fosses 346 (64)9)

NRC FORM 366A (64)9)U.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)TEXT CONTINUATION t APPROVED OMB NO.31504104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P.530), U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON.

DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.FACILITY NAME (1)DOCKET NUMBER (2)YEAR LER NUMBER (6)SEQUENTIAL NUMBER REVISION NVMBER PAGE (3)D.C.Cook Nuclear Plant-Unit 1 TEXT///moro 4O4co/4 roqo/rod, Ir Jo odds/orM/HRC Form 36649/(17)0 5 0 0 0 3]5 9 0 0 4 0 0 0 2 QF 0 Conditions Prior to Occurrence Unit one (U-1)in mode one at 89.9X power.Unit two (U-2)in mode six at OX power.Descri tion of Event On 4-20-92, the 1-OHP 4030.STP.002V (Boration System Valve Position Verification and Testing)surveillance procedure was not performed to satisfy the Technical Specification (TS)surveillance requirement 4.1.2.2.a.l for TS 3.1.2.2 (Reactivity Control Systems Flow Paths-Operation).

TS 4.1.2.2.a.l requires at least once per seven days that the boration flow paths from the refueling water storage tank (RWST)(EIIS/CB-TK) and the boric acid storage tank (BAST)(EIIS/CB-TK) be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.The missed surveillance procedure was discovered by an Operations Department Engineer on 4-24-92.The surveillance test was last performed on 4-13-92.The TS action statement was entered at 1255 hours0.0145 days <br />0.349 hours <br />0.00208 weeks <br />4.775275e-4 months <br /> and the 1-OHP 4030.STP.002V surveillance procedure was started, completed, and reviewed by 1314 hours0.0152 days <br />0.365 hours <br />0.00217 weeks <br />4.99977e-4 months <br /> on 4-24-92.A review of the completed surveillance noted that the surveillance acceptance criteria were satisfied and the action statement was exited at this time.On 4-20-92, the involved Unit Supervisor (Senior Reactor Operator)reviewed the 1-OHP 4030.STP.002V paperwork completed during his shift.Following this review, the Unit Supervisor recorded the completed sections of the 1-OHP 4030.STP.002V surveillance procedure in the Master Surveillance Schedule.While recording the completed sections of the surveillance procedure just reviewed, the Unit Supervisor incorrectly recalled that the weekly surveillance section of the procedure had been completed and signed off the weekly surveillance procedure as complete.Following the performance of the surveillances listed on the schedule, the Operations Department Engineering Section conducts a review of the completed surveillance paperwork.

During this surveillance paperwork review, the engineers identified on 4-21-92 that the 1-OHP 4030.STP.002V weekly surveillance procedure sheets were missing.Upon discovering that NR C Form 366A (64)9)

NRC FORM 366A (64)9)U IL NUCLEAR REGULATORY COMMISSION LICENSEE EVEN EPORT (LER)TEXT CONTINUATION APPROVED OMB NO.31500104 EXPIRESI 4/30/92 ESTI ED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HAS, FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P-530).V.S.NVCI.EAR REGULATORY COMMISSION, WASHINGTON.

DC 20555, AND TO 1'HE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.FACILITY NAME (1)DOCKET NUMBER (2)YEAR LER NUMBER (6)SEOVENTIAL NUMSER REVISION NUMBER PAGE (3)D.C.Cook Nuclear Plant-Unit 1 TEXT/l/moro Epoco/1 rorlur)od, uro oddldooo/NRC Form 3664 9/07)0 5 0 0 0 3]5 9 2 0 0 4 0 0 0 3 QF 0 the weekly surveillance procedure sheets were missing, the engineers documented that the weekly surveillance procedure was in grace by recording the status in the grace section of the Surveillance Status Summary Report.Although the engineers identified that the weekly surveillance was apparently in grace due to the missing paperwork, the engineers did not pursue further why the surveillance procedure had not been completed.

This was based on the engineers'ast experience had shown that the control room operators also track incomplete surveillances and pursue the completion of a surveillance before the grace period expires.Cause of Event The cause for the missed surveillance was personnel error.The Unit Supervisor developed a mind set during the surveillance review that the surveillance was completed and therefore signed off the surveillance procedure as complete on the schedule.In addition, the engineers had a mind set that control room operators record and track surveillances in grace and that the control room operators were aware that the surveillance had not been completed, or that the paperwork must have been routed to the engineers and had not arrived.Therefore, the engineers did not pursue further the completion of the surveillance.

A~nal sis Technical Specification (TS)4.1.2.2.a.l (Reactivity Control Systems Flow Paths-Operating) requires at least once per seven days the boration flow paths from the refueling water storage tank (RWST)and the boric acid storage tank (BAST)to be proven operable by cycling each testable power-operated or automatic valve in the flow path through at least one complete cycle of full travel.The failure to perform the surveillance is a violation of Technical Specification 3.1.2.2 and is reportable under 10 CFR 50s73 (a)(2)(i)(B).

Following the identification of the missed surveillance, the 1-OHP 4030.STP.002V surveillance procedure was performed to satisfy the requirements of TS 4.1.2.2.a.l.

A review of the completed surveillance noted that the requirements of the surveillance procedure were met.Therefore, it is concluded that the valves tested by the surveillance procedure would have performed their safety function if required during the time period from the last completed surveillance procedure on 4-13-92 and the surveillance procedure performed on 4-24-92.NAC Form 366A (84)9)

NRC FORM 366A (64)9)U.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVEN EPORT (LER)TEXT CONTINUATION APPROVED OMB NO.31504(04 EXPIRESI 4/30/02 ESTI FD BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 500 HRS.FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P430), U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.FACILITY NAME (1)~DOCKET NUMBER (2)LER NUMBER (6)PAGE (3)D.C.Cook Nuclear Plant-Unit 1 TEXT N mort trrtct is ttqur)td, u>>4ddrrr'ootr HRC Form 3664'tl l)7)YEAR 3 1 5 9 2 SEQUENTIAI.

NUMBER 0 0 4 5+(REVISION NUMBER 0 0 0 40F 0 Based upon the above analysis, the failure to perform the surveillance procedure within the grace period is not considered to have created a significant safety concern, nor did the missed surveillance create a significant hazard to the health and safety of the general public.Corrective Action Following the identification that the portion of the 1-OHP 4030.STP.002V surveillance procedure had not been performed, the 1-OHP 4030~STP.002V surveillance procedure was satisfactorily completed.

2.The Shift Supervisor reviewed The finding of this investigation with the involved Unit Supervisor.

This review included a discussion of the Unit Supervisor responsibility and accountability for the performance and documentation of surveillance procedures.

3.The Operations Department Production Supervisor, reviewed the finding of this.investigation with the engineers involved.Previous Similar Events A review of the License Event Reports did not identify a similar event.NRC Form 366A (64)B)