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| issue date = 11/14/1994
| issue date = 11/14/1994
| title = LER 94-012-00:on 941013,required Daily Calibr of Power Range Instrumentation Not Performed within Surveillance Interval Due to Personnel Error.Personnel Involved in Event Counseled & Procedure SC.OP-DD-ZZ-0D40(Z) revised.W/941114 Ltr
| title = LER 94-012-00:on 941013,required Daily Calibr of Power Range Instrumentation Not Performed within Surveillance Interval Due to Personnel Error.Personnel Involved in Event Counseled & Procedure SC.OP-DD-ZZ-0D40(Z) revised.W/941114 Ltr
| author name = HAGAN J J, PASTVA M J
| author name = Hagan J, Pastva M
| author affiliation = PUBLIC SERVICE ELECTRIC & GAS CO. OF NEW JERSEY
| author affiliation = PUBLIC SERVICE ELECTRIC & GAS CO. OF NEW JERSEY
| addressee name =  
| addressee name =  
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=Text=
=Text=
{{#Wiki_filter:_;... p,., }t' \:) . e Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station U. S. Nuclear Regulatory Cormnission Document Control Desk Washington, DC 20555 Attn.: Document Control Desk SALEM GENERATING STATION LICENSE NO. DPR-75 DOCKET NO. 50-311 UNIT NO. 2 LICENSEE EVENT REPORT NO. 94-012-00 November 14, 1994 This Licensee Event Report is being submitted pursuant to the requirements of Code of Federal Regulation 10CFR50. 73 (a) (2) (i) (B). Issuance of this report is required within thirty (30) days of event discovery.
{{#Wiki_filter:(    ' ~ ; ,
Sincerely, MJPJ:vs C -Distribution LER File 9411210395 941114 PDR ADDCK 05000311 {p?) / S PDR l he power in y1JUT han.3-. 95-2189 REV 7-92 NRC FORM 366 (5-92) .S. NUCLl;AR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104  
          }t'    PS~G    p,.,
-. EXPIRES 5/31/95 LICENSEE EVENT REPORT (LER) (See reverse for required number of digits/characters for each block) ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY .COMMISSION, .WASHINGTON, De 20555*0001, AND TO THE PAPERWORK REDUCTION .PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503. FACILITY NAME (1) DOCKET NUMBER (2) PAGE (31 1 OF05 Salem Generating Station Unit 2 05000 311 TtTLE(4) La.LOrimer:ric  
                          \:)
\,Heat tlal.anceJ .L;al.cul.at.ions Not Performed Within the Specified Surveillance Interval On Both Units -. EVENT DATE (5) LEA NUMBER (6 REPORT NUMBER '71 OTHER FACILITIES INVOLVED (8 SEQUENTIAL MONTH DAY YEAR NUMBER 10 13 94 94 012 REVISION NUMBER 00 MONTH ' 11 .VEAR 14 . 94 FACILITY NAME DOCKET NUMBER Salem Unit 1 05000?72 FACILITY NAME DOCKET NUMBER 05000 OPERATING 1 THIS REPORT IS SUBMITTED PURSUANT TO'THE REQUIREMENTS OF 10 CFR §: {Check one or more (11 MODE (9) 20.402(b) 20.405{c) 50.73{a)(2)(iv) 73.71 (b) POWER 100% 20.405(a)(1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71 (c) LEVEL (10) 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii)
9                                    e
OTHER -. 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) (Specify in Abstract n-+--.:....:....:...:...,:.....:._
      \~'--              .
__ ___; __ 4.......-1--__:_..:....:....:..:_:,.----__,.+_,...+--:....:_:...:.,:__:_::_.:_---t below and in Text, NRC
Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station November 14, 1994 U. S. Nuclear Regulatory Cormnission Document Control Desk Washington, DC 20555 Attn.: Document Control Desk SALEM GENERATING STATION LICENSE NO. DPR-75 DOCKET NO. 50-311 UNIT NO. 2 LICENSEE EVENT REPORT NO. 94-012-00 This Licensee Event Report is being submitted pursuant to the requirements of Code of Federal Regulation 10CFR50. 73 (a) (2) (i) (B). Issuance of this report is required within thirty (30) days of event discovery.
* 20.405(a)(1)(iv)
Sincerely, MJPJ:vs C   -Distribution LER File
X 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B)
{p?)
Form 366A) ,,,.,. 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)
I~
LICENSEE CONTACT FOR THIS LEA (12\ NAME Michael J. Pastva -LER Coordinator TELEPHONE NUMBER (Include Area Code) 609 339-5165 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13\ CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TO NPRDS CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TONPRDS SUPPLEMENTAL REPORT EXPECTED (14\ EXPECTED MONTH DAY YEAR I YES X NO . . (If yes, complete EXPECTED SUBMISSION DATE) SUBMISSION DATE (15) _ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16) On 10/13/94, required daily calibration of power range instrumentation was not performed.
9411210395 941114 PDR ADDCK 05000311                                                                     /
Investigation revealed that during 1994 qn 1/8,, 7/5, 7/8, and 9/12 (Unit 2), and 2/26, 3/5, and 9/2 (Unit 1), the calibration was performed beyond the allowable.extension Technical Specification (TS) 4.0.2. These events are attributed to personnel error due to failure to follow procedure.
S                           PDR l he power i~ in y1JUT han.3-.
contributors to the 10/13 event were focus upon ongoing activities and common mis-perception (applicable to all the events) that the surveillance could be completed within 'the confines of a calendar day. Licensed personnel from the 10/13 event were counseled concerning their actions and Management expectations.
95-2189 REV 7-92
Operations Night Order Book entries were made to explain* the surveillance requirement and a procedure revision to enhance/clarify the surveillance interval.
 
All Licensed personnel and select Technical Department personnel, will review these events to ensure their understanding of the surveillance,interval.
NRC FORM 366                                                       .S. NUCLl;AR REGULATORY COMMISSION                           APPROVED BY OMB NO. 3150-0104 -
During the present re-qualification cycle, all licensed personnel will receive
(5-92)                                                                                                                                . EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.               FORWARD LICENSEE EVENT REPORT (LER)                                                              COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY .COMMISSION, .WASHINGTON, De 20555*0001, AND TO THE PAPERWORK REDUCTION .PROJECT (3150-0104), OFFICE OF (See reverse for required number of digits/characters for each block)                            MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
* training specific to these events. By additional procedure enhancement will be made to provide more focus on TS requirements and address human factors tied to procedure performance and review. NRC FORM 366 (5*92) e REQUIRED OF DIGITS/CHARACTE.
FACILITY NAME (1)                                                                                                       DOCKET NUMBER (2)                                     PAGE (31 Salem Generating Station Unit 2                                                                                                   05000 311                             1 OF05 TtTLE(4) La.LOrimer:ric \,Heat tlal.anceJ .L;al.cul.at.ions Not Performed Within the Specified Surveillance Interval On Both Units -                                                           .
FOR EACH BLOCK -BLOCK NUMBER OF NUMBER DIGITS/CHARACTERS TITLE ' 1 UP TO 46 FACILITY NAME 2 8 TOTAL 3 IN ADDITION TO 05000 DOCKET NUMBER 3 VARIES PAGE NUMBER 4 UP TO 76 TITLE 5 6 TOTAL 2 PER BLOCK EVENT DATE 7 TOTAL 6 2 FOR YEAR 3 FOR SEQUENTIAL NUMBER LER NUMBER _ 2 FOR REVISION NUMBER 7 6 TOTAL 2 PER BLOCK REPORT DATE UP TO 18 -FACILITY NAME 8 8 TOTAL -DOCKET NUMBER OTHER FACILITIES INVOLVED 3 IN ADDITION TO 05000 9 1 OPERATING MODE 10 3 POWER LEVEL 11 1 CHECK BOX THAT APPLIES REQUIREMENTS OF 10 CFR 12 UP TO 50 FOR NAME 14 FOR TELEPHONE LICENSEE CONT ACT CAUSE VARIES 2 FOR SYSTEM 13 4 FOR COMPONENT EACH COMPONENT FAILURE 4 FOR MANUFACTURER  
EVENT DATE (5)                                 LEA NUMBER (6                       REPORT NUMBER '71                       OTHER FACILITIES INVOLVED (8 FACILITY NAME                              DOCKET NUMBER SEQUENTIAL         REVISION                      .VEAR MONTH               DAY     YEA~      YEAR                                               MONTH '
' NPRDS VARIES 14 , CHECK BOX THAT APPLIES -SUPPLEMENTAL REPORT EXPECTED 15 6 TOTAL 2 PER BLOCK EXPECTED SUBMISSION DATE 
NUMBER            NUMBER                                   Salem Unit 1                              05000?72 FACILITY NAME                              DOCKET NUMBER 10                  13     94       94                   012                 00         11       14 . 94                                                       05000 OPERATING                 1     THIS REPORT IS SUBMITTED PURSUANT TO'THE REQUIREMENTS OF 10 CFR §: {Check one or more (11 MODE (9)                           20.402(b)                                       20.405{c)                               50.73{a)(2)(iv)                     73.71 (b)
,* LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station Unit 2 DOCKET NUMBER 5000311 PLANT AND SYSTEM IDENTIFICATION:.
POWER                 100%       20.405(a)(1)(i)                                 50.36(c)(1)                             50.73(a)(2)(v)                     73.71 (c)
Westinghouse  
LEVEL (10)                           20.405(a)(1)(ii)                               50.36(c)(2)                             50.73(a)(2)(vii)                   OTHER
-Pressurized Water Reactor LER NUMBER* 94-012-00 PAGE 2 of 5 Energy Industry Identification System (EIIS) codes are identified in the text as {xx} IDENTIFICATION OF OCCURRENCES:
                        .               20.405(a)(1)(iii)                               50.73(a)(2)(i)                           50.73(a)(2)(viii)(A)           (Specify in Abstract n-+--.:....:....:...:...,:.....:.__ ____;_ _4.......-1--__:_..:....:....:..:_:,.----__,.+_,...+--:....:_:...:.,:__:_::_.:_---t below and in Text, NRC
Calorimetric (Heat Balance) Calculations Not Performed Within The specif Surveillance Interval On Both Units ' . Event Dates: (Unit 2) 1/8/94, 7/5/94, 7/8/94, 9/12/94, and 10/13/94 (Unit 1) 2/26/94, 3/5/94, arid 9/2/94 Discovery Date: 10/13/94 Report Date:
* 20.405(a)(1)(iv)                             X 50.73(a)(2)(ii)                         50.73(a)(2)(viii)(B)           Form 366A) 20.405(a)(1)(v)                               50.73(a)(2)(iii)                         50.73(a)(2)(x)
* 11/14/94 This report was initiated by Incident Report No. 94-304. DESCRIPTION OF OCCURRENCES:
LICENSEE CONTACT FOR THIS LEA (12\
At approximately 0951 on October 12, 1994, the requirements of Technical Specification (TS) Tabl.e 4. 3-1, Item 2, for daily calibration of power range instrumentation
- NAME                 Michael J. Pastva - LER Coordinator                                                                       TELEPHONE NUMBER (Include Area Code) 609 339-5165 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13\
{IG} when above 15% of RATED THERMAL POWER, were met through satisfactory completion of the caloriinetric (heat balance-)
REPORTABLE                                                                                    REPORTABLE CAUSE         SYSTEM         COMPONENT           MANUFACTURER                                           CAUSE       SYSTEM     COMPONENT       MANUFACTURER TO NPRDS                                                                                        TONPRDS SUPPLEMENTAL REPORT EXPECTED (14\                                                               EXPECTED           MONTH       DAY     YEAR X                                                      SUBMISSION I YES (If yes, complete EXPECTED SUBMISSION DATE)
calculation.
NO .
At 0530 hours on October 13, 1994, with reactor power at 100%, a controlled reactor shutdown, at 5% per hour, was begun in preparation for refueling outage 2R8. At approximately 2200 hours (same day), decrease to 15% power was achieved and, at 2244 hours (same day), the Unit was placed in MODE 3 (HOT STANDBY).
_ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)
On October 13, 1994, the surveillance requirements of TS Table 4.3-1, Item 2, (including the maximum allowable extension per TS 4.0.2) were not met, due to failure to perform the once per 24 hours calibration of power range instrumentation.
DATE (15)
Event discovery occurred on October 14, 1994. Investigation revealed other instances on both Units during 1994, where the surveillance requirements of TS Table 4.3-1 were performed beyond the allowable extension per TS 4.0.2: Unit 2 -January 8 *(reactor power 98.8%), July 5 (reactor power 43.3%), July 8 (reactor power 72.7%), and September 12 (reactor power 93.8%) and Unit 1 -February 26 (reactor power 70.6%), March 5 (99.0%) and September 2 (reactor power , ' I I 
On 10/13/94, required daily calibration of power range instrumentation was not performed. Investigation revealed that during 1994 qn 1/8,,
.. LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating station Unit 2 ANALYSIS OF OCCURRENCES:
7/5, 7/8, and 9/12 (Unit 2), and 2/26, 3/5, and 9/2 (Unit 1), the calibration was performed beyond the allowable.extension p~r Technical Specification (TS) 4.0.2. These events are attributed to personnel error due to failure to follow procedure. contributors to the 10/13 event were focus upon ongoing activities and common mis-perception (applicable to all the events) that the surveillance could be completed within 'the confines of a calendar day. Licensed personnel from the 10/13 event were counseled concerning their actions and Management expectations. Operations Night Order Book entries were made to explain* the surveillance requirement and a procedure revision to enhance/clarify the surveillance interval. All Licensed personnel and select Technical Department personnel, will review these events to ensure their understanding of the surveillance,interval. During the present re-qualification cycle, all licensed personnel will receive
DOCKET NUMBER 5000311 LER NUMBER 94-012-00 PAGE 3 of 5 TSs specify that the nuclear instrumentation system (NIS) power range calibration be performed at least once per 24 hours, whenever rated thermal power (RTP) is greater than 15%. Procedure S2.RE-ST.ZZ-0001(Q), "CALORIMETRIC"CALCULATION", is used to complete this calibration.
* training specific to these events. By 2/28/95~ additional procedure enhancement will be made to provide more focus on TS requirements and address human factors tied to procedure performance and review.
In addition, during Monday through Friday, the Technical Department assists the Operations Department in the performance of this procedure.
NRC FORM 366 (5*92)
The "DAILY ROUTINES" checklist log of Operations Directive Procedure, SC.OP-DD.ZZ-OD40(Z), "SHIFT ROUTINES", Step 5.16, specifies the time frame for surveillance performance as oaoo-1200 hours. In addition, the procedure description for Step 5.16 states "The interval between calorimetrics shall not exceed 24 hours".
 
* On October 13, 1994, Unit 2 operated above 15% power for approximately six hours and 53 minutes beyond the maximum allowable extension for the required .NISpower range calibration.
e       REQUIRED NUM~ER  OF DIGITS/CHARACTE.
As such, approximately 36 hours transpired*
FOR EACH BLOCK -
between the prior NIS calibration and when RTP was 15%. Other instances occurred on both Units where the maximum allowable extension for the required NIS power range calibration was exceeded; Unit' 2*-two hours, 55 minutes; five hours,* 25 minutes; six hours, 19 minutes; and eight hours, 14 minutes; and Unit 1 -two hours, 42 minutes; 9 minutes; and three hours. APPARENT CAUSE OF OCCURRENCES:
BLOCK           NUMBER OF TITLE NUMBER     DIGITS/CHARACTERS 1             UP TO 46                 FACILITY NAME 8 TOTAL 2                                        DOCKET NUMBER 3 IN ADDITION TO 05000 3                 VARIES                 PAGE NUMBER 4               UP TO 76                 TITLE 6 TOTAL 5                                        EVENT DATE 2 PER BLOCK 7 TOTAL 2 FOR YEAR 6                                        LER NUMBER 3 FOR SEQUENTIAL NUMBER
These events are attributed to "Personnel Error", as classified in Appendix B of NUREG_-1022.
_ 2 FOR REVISION NUMBER 6 TOTAL 7                                        REPORT DATE 2 PER BLOCK UP TO 18 - FACILITY NAME 8                                       OTHER FACILITIES INVOLVED 8 TOTAL - DOCKET NUMBER 3 IN ADDITION TO 05000 9                   1                   OPERATING MODE 10                 3                     POWER LEVEL 1
The event of October 13, 1994 resulted from failure of the Nuclear Control Operator (NCO) to follow procedure
11                                        REQUIREMENTS OF 10 CFR CHECK BOX THAT APPLIES UP TO 50 FOR NAME 12                                        LICENSEE CONT ACT 14 FOR TELEPHONE CAUSE VARIES 2 FOR SYSTEM 13       4 FOR COMPONENT                 EACH COMPONENT FAILURE 4 FOR MANUFACTURER
[Step 5.16 of SC.OP-DD.ZZ-OD40(Z)]
      '         NPRDS VARIES 14                                       SUPPLEMENTAL REPORT EXPECTED CHECK BOX THAT APPLIES -
combined with failure of the Nuclear Shift Supervisor (NSS) to adequately review the completed shift routines.
6 TOTAL 15                                        EXPECTED SUBMISSION DATE 2 PER BLOCK
A contributor was focus upon activities related to the ongoing Unit power reduction and removal the Unit from_service for the upcoming refueling outage. Another contributor was a common mis-perception that the surveillance interval was once per calendar day and that the surveillance could be delayed within the confines of a calendar day, until establishing a stable plant condition which would allow performance of the surveillance.
 
Existence of this misperception is reinforced by discovery of the additional events where the surveillance was not completed with the required time period. Analysis of failed barriers indicates the personnel errors were the result of less than adequate knowledge and training.
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station           DOCKET NUMBER      LER NUMBER*      PAGE Unit 2                               5000311         94-012-00      2 of 5 PLANT AND SYSTEM IDENTIFICATION:.
Thi? was evidenced by the misunderstanding the once per 24 hours surveillance requirement.
Westinghouse   - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes are identified in the text as {xx}
1-.. I. I --LICENSEE EVENT REPORT (LER) TEXT CONTINUATION
IDENTIFICATION   OF OCCURRENCES:
* Salem Generating Station Unit 2 PREVIOUS OCCURRENCES:
Calorimetric (Heat Balance) Calculations Not Performed Within The specif ~ed Surveillance Interval On Both Units               '
DOCKET NUMBER 5000311 LER NUMBER 94-012-00 PAGE 4 of 5 Previous events involving the.failure to perform the required daily NIS calibration occurred on December 8, 15, 16, and 26, 1977. These were identified as an.infraction in a Notice of Violation in NRC Inspection Report 50-272/78-02, dated February 17, 1978. The cause of these occurrences was attributed to ongoing Unit load transients,
      . Event Dates:     (Unit 2) 1/8/94, 7/5/94, 7/8/94, 9/12/94, and 10/13/94 (Unit 1) 2/26/94, 3/5/94, arid 9/2/94 Discovery Date:     10/13/94 Report Date:
* 11/14/94 This report was initiated by Incident Report No. 94-304.
DESCRIPTION OF OCCURRENCES:
At approximately 0951 ho~rs on October 12, 1994, the requirements of Technical Specification (TS) Tabl.e 4. 3-1, Item 2, for daily calibration of power range instrumentation {IG} when above 15% of RATED THERMAL POWER, were met through satisfactory completion of the caloriinetric (heat balance-) calculation.
At 0530 hours on October 13, 1994, with reactor power at 100%, a controlled reactor shutdown, at 5% per hour, was begun in preparation for refueling outage 2R8. At approximately 2200 hours (same day),
decrease to 15% power was achieved and, at 2244 hours (same day), the Unit was placed in MODE 3 (HOT STANDBY). On October 13, 1994, the surveillance requirements of TS Table 4.3-1, Item 2, (including the maximum allowable extension per TS 4.0.2) were not met, due to failure to perform the once per 24 hours calibration of power range instrumentation. Event discovery occurred on October 14, 1994.
Investigation revealed other instances on both Units during 1994, where the surveillance requirements of TS Table 4.3-1 were performed beyond the allowable extension per TS 4.0.2: Unit 2 - January 8
      *(reactor power 98.8%), July 5 (reactor power 43.3%), July 8 (reactor power 72.7%), and September 12 (reactor power 93.8%) and Unit 1 -
February 26 (reactor power 70.6%), March 5 (99.0%) and September 2 (reactor power 39.9%)~            ,
 
..                 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating station       DOCKET NUMBER     LER NUMBER       PAGE Unit 2                          5000311          94-012-00       3 of 5 ANALYSIS OF OCCURRENCES:
TSs specify that the nuclear instrumentation system (NIS) power range calibration be performed at least once per 24 hours, whenever rated thermal power (RTP) is greater than 15%. Procedure S2.RE-ST.ZZ-0001(Q), "CALORIMETRIC"CALCULATION", is used to complete this calibration. In addition, during Monday through Friday, the Technical Department assists the Operations Department in the performance of this procedure. The "DAILY ROUTINES" checklist log of Operations Directive Procedure, SC.OP-DD.ZZ-OD40(Z), "SHIFT ROUTINES", Step 5.16, specifies the time frame for surveillance performance as oaoo-1200 hours. In addition, the procedure description for Step 5.16 states "The interval between calorimetrics shall not exceed 24 hours".
* On October 13, 1994, Unit 2 operated above 15% power for approximately six hours and 53 minutes beyond the maximum allowable extension for the required .NISpower range calibration. As such, approximately 36 hours transpired* between the prior NIS calibration and when RTP was 15%.
Other instances occurred on both Units where the maximum allowable extension for the required NIS power range calibration was exceeded; Unit' 2*- two hours, 55 minutes; five hours,* 25 minutes; six hours, 19 minutes; and eight hours, 14 minutes; and Unit 1 - two hours, 42 minutes; 9 minutes; and three hours.
APPARENT CAUSE OF OCCURRENCES:
These events are attributed to "Personnel Error", as classified in Appendix B of NUREG_-1022. The event of October 13, 1994 resulted from failure of the Nuclear Control Operator (NCO) to follow procedure [Step 5.16 of SC.OP-DD.ZZ-OD40(Z)] combined with failure of the Nuclear Shift Supervisor (NSS) to adequately review the completed shift routines. A contributor was focus upon activities related to the ongoing Unit power reduction and removal o~ the Unit from_service for the upcoming refueling outage. Another contributor was a common mis-perception that the surveillance interval was once per calendar day and that the surveillance could be delayed within the confines of a calendar day, until establishing a stable plant condition which would allow performance of the surveillance. Existence of this misperception is reinforced by discovery of the additional events where the surveillance was not completed with the required time period. Analysis of failed barriers indicates the personnel errors were the result of less than adequate knowledge and training. Thi?
was evidenced by the misunderstanding the once per 24 hours surveillance requirement.
 
1- ..
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION
* Salem Generating Station       DOCKET NUMBER   LER NUMBER         PAGE Unit 2                            5000311        94-012-00         4 of 5 PREVIOUS OCCURRENCES:
Previous events involving the.failure to perform the required daily NIS calibration occurred on December 8, 15, 16, and 26, 1977.     These were identified as an.infraction in a Notice of Violation in NRC Inspection Report 50-272/78-02, dated February 17, 1978. The cause of these occurrences was attributed to ongoing Unit load transients,
* which did not permit the required stable conditions to.allow*
* which did not permit the required stable conditions to.allow*
completion of the surveillance.
completion of the surveillance. Corrective action included an Operations Night Order Book {NOB) entry on 1/28/78, instructing the Senior Nuclear Shift Supervisor {SNSS) of the necessity to perform the _surveillance. This NOB entry directed the SNSS to stop a load change, if required, to permit completion of the surveillanc.e within th_e required till\e frame.
Corrective action included an Operations Night Order Book {NOB) entry on 1/28/78, instructing the Senior Nuclear Shift Supervisor
SAFETY SIGNIFICANCE:
{SNSS) of the necessity to perform the _surveillance.
These events are reportable pursuant to 10CFR50.73{a) (2) (i) (B), due to failure to comply with the Limiting Condition For Operation requirements of TS Table 4.3-1, as well as TS 3.0.2, due to failure to perform the surveillance requirements within the.maximum allowable extension.
This NOB entry directed the SNSS to stop a load change, if required, to permit completion of the surveillanc.e within th_e required till\e frame. SAFETY SIGNIFICANCE:
The safety signif i~ance of October 13 event is minimal as the approximate six hours 53 minutes the Unit operated until the requirements of TS no longer applied (i.e. entry into.MODE 3) is bounded by the requirements of TS 3.0.3.. The safety significance of the other occurrences is minimal based upon satisfactory completion of the surveillance following each event. In addition, in accordance with procedure, reaqtor power is maintained less than 100% and verified by an on-line calorimetric computer readout. The inputs to the on-line calorimetric computer readout are the same as the manual surveillance calculation.
These events are reportable pursuant to 10CFR50.73{a)
CORRECTIVE ACTION:
(2) (i) (B), due to failure to comply with the Limiting Condition For Operation requirements of TS Table 4.3-1, as well as TS 3.0.2, due to failure to perform the surveillance requirements within the.maximum allowable extension.
All Licensed personnel involved in the October 13 event have been counseled concerning their *actions and Management expectations regarding procedure compliance.
The safety signif of October 13 event is minimal as the approximate six hours 53 minutes the Unit operated until the requirements of TS no longer applied (i.e. entry into.MODE
An Operations NOB entry, explaining the surveillance requirement, was issued on.October 26, 1994.
: 3) is bounded by the requirements of TS 3.0.3.. The safety significance of the other occurrences is minimal based upon satisfactory completion of the surveillance following each event. In addition, in accordance with procedure, reaqtor power is maintained less than 100% and verified by an on-line calorimetric computer readout. The inputs to the on-line calorimetric computer readout are the same as the manual surveillance calculation.
SC.OP-DD.ZZ-OD40{Z) has been revised to enhance arid clarify the definition of. the surveillance interval. Additionally, a NOB entry was made on November 8, 199*4, describing the procedure change and requiring all Senior Shift Supervisors to review this change with their licensed personnel.
CORRECTIVE ACTION: All Licensed personnel involved in the October 13 event have been counseled concerning their *actions and Management expectations regarding procedure compliance.
 
An Operations NOB entry, explaining the surveillance requirement, was issued on.October 26, 1994. SC.OP-DD.ZZ-OD40{Z) has been revised to enhance arid clarify the definition of. the surveillance interval.
*                     .e LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating station       DOCKET NUMBER     LER NUMBER       PAGE Unit 2                          5000311        94-012-00       5 of 5 CORRECTIVE ACTION:  (cont'd)
Additionally, a NOB entry was made on November 8, 199*4, describing the procedure change and requiring all Senior Shift Supervisors to review this change with their licensed personnel.
As a result of these events, a review of all Operations TS surveillance requirements with frequencies of 24 hours or less was performed to ensure TS compliance. This review identified four surveillances that, although presently adequate, will be procedurally enhanced as part of the SC.OP-DD.ZZ-OD40(Z) revision effort.
* .e LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating station Unit 2 CORRECTIVE ACTION: (cont'd) DOCKET NUMBER 5000311 LER NUMBER 94-012-00 PAGE 5 of 5 As a result of these events, a review of all Operations TS surveillance requirements with frequencies of 24 hours or less was performed to ensure TS compliance.
To ensure a clear understanding of the surveillance requirement, it has been specified, verbatim, in S1(2).RE-ST.ZZ-OOOl(Q). This procedure change has been discussed with select Technical Department personnel, who perform this requirement.
This review identified four surveillances that, although presently adequate, will be procedurally enhanced as part of the SC.OP-DD.ZZ-OD40(Z) revision effort. To ensure a clear understanding of the surveillance requirement, it has been specified, verbatim, in S1(2).RE-ST.ZZ-OOOl(Q).
* Based on interviews with involved personnel, Operations Management will revise SC.OP-DD.ZZ-OD40(Z), by February 28, 1995, to separate TS surveillance requirements from other routine evolutions. This change is intended.to provide more focus on TS requirements and-address human factors tied to performance and review of the procedure.
This procedure change has been discussed with select Technical Department personnel, who perform this requirement.
* Based on interviews with involved personnel, Operations Management will revise SC.OP-DD.ZZ-OD40(Z), by February 28, 1995, to separate TS surveillance requirements from other routine evolutions.
This change is intended.to provide more focus on TS requirements and-address human factors tied to performance and review of the procedure.
All Licensed personnel and select members of the Technical Department, will review these events to ensure their understanding of
All Licensed personnel and select members of the Technical Department, will review these events to ensure their understanding of
* the surveillance interval.
* the surveillance interval.
During the present re-qualification cycle, all licensed personnel will receive training specific to these events and TS surveillance interval requirements.
During the present re-qualification cycle, all licensed personnel will receive training specific to these events and TS surveillance interval requirements. Additionally, the Training Department will review the initial ~icensing Program -to ensure proper focus on TS interval requirements. The aforementioned training and review will encompass both Salem and Hope Creek programs.
Additionally, the Training Department will review the initial Program -to ensure proper focus on TS interval requirements.
The aforementioned training and review will encompass both Salem and Hope Creek programs.
MJPJ:pc SORC Mtg. 94-087}}
MJPJ:pc SORC Mtg. 94-087}}

Latest revision as of 10:13, 23 February 2020

LER 94-012-00:on 941013,required Daily Calibr of Power Range Instrumentation Not Performed within Surveillance Interval Due to Personnel Error.Personnel Involved in Event Counseled & Procedure SC.OP-DD-ZZ-0D40(Z) revised.W/941114 Ltr
ML18101A334
Person / Time
Site: Salem PSEG icon.png
Issue date: 11/14/1994
From: Hagan J, Pastva M
Public Service Enterprise Group
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-94-012-02, LER-94-12-2, NUDOCS 9411210395
Download: ML18101A334 (7)


Text

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Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station November 14, 1994 U. S. Nuclear Regulatory Cormnission Document Control Desk Washington, DC 20555 Attn.: Document Control Desk SALEM GENERATING STATION LICENSE NO. DPR-75 DOCKET NO. 50-311 UNIT NO. 2 LICENSEE EVENT REPORT NO. 94-012-00 This Licensee Event Report is being submitted pursuant to the requirements of Code of Federal Regulation 10CFR50. 73 (a) (2) (i) (B). Issuance of this report is required within thirty (30) days of event discovery.

Sincerely, MJPJ:vs C -Distribution LER File

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9411210395 941114 PDR ADDCK 05000311 /

S PDR l he power i~ in y1JUT han.3-.

95-2189 REV 7-92

NRC FORM 366 .S. NUCLl;AR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 -

(5-92) . EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD LICENSEE EVENT REPORT (LER) COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY .COMMISSION, .WASHINGTON, De 20555*0001, AND TO THE PAPERWORK REDUCTION .PROJECT (3150-0104), OFFICE OF (See reverse for required number of digits/characters for each block) MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) PAGE (31 Salem Generating Station Unit 2 05000 311 1 OF05 TtTLE(4) La.LOrimer:ric \,Heat tlal.anceJ .L;al.cul.at.ions Not Performed Within the Specified Surveillance Interval On Both Units - .

EVENT DATE (5) LEA NUMBER (6 REPORT NUMBER '71 OTHER FACILITIES INVOLVED (8 FACILITY NAME DOCKET NUMBER SEQUENTIAL REVISION .VEAR MONTH DAY YEA~ YEAR MONTH '

NUMBER NUMBER Salem Unit 1 05000?72 FACILITY NAME DOCKET NUMBER 10 13 94 94 012 00 11 14 . 94 05000 OPERATING 1 THIS REPORT IS SUBMITTED PURSUANT TO'THE REQUIREMENTS OF 10 CFR §: {Check one or more (11 MODE (9) 20.402(b) 20.405{c) 50.73{a)(2)(iv) 73.71 (b)

POWER 100% 20.405(a)(1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71 (c)

LEVEL (10) 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) OTHER

. 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) (Specify in Abstract n-+--.:....:....:...:...,:.....:.__ ____;_ _4.......-1--__:_..:....:....:..:_:,.----__,.+_,...+--:....:_:...:.,:__:_::_.:_---t below and in Text, NRC

  • 20.405(a)(1)(iv) X 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) Form 366A) 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)

LICENSEE CONTACT FOR THIS LEA (12\

- NAME Michael J. Pastva - LER Coordinator TELEPHONE NUMBER (Include Area Code) 609 339-5165 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13\

REPORTABLE REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER CAUSE SYSTEM COMPONENT MANUFACTURER TO NPRDS TONPRDS SUPPLEMENTAL REPORT EXPECTED (14\ EXPECTED MONTH DAY YEAR X SUBMISSION I YES (If yes, complete EXPECTED SUBMISSION DATE)

NO .

_ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)

DATE (15)

On 10/13/94, required daily calibration of power range instrumentation was not performed. Investigation revealed that during 1994 qn 1/8,,

7/5, 7/8, and 9/12 (Unit 2), and 2/26, 3/5, and 9/2 (Unit 1), the calibration was performed beyond the allowable.extension p~r Technical Specification (TS) 4.0.2. These events are attributed to personnel error due to failure to follow procedure. contributors to the 10/13 event were focus upon ongoing activities and common mis-perception (applicable to all the events) that the surveillance could be completed within 'the confines of a calendar day. Licensed personnel from the 10/13 event were counseled concerning their actions and Management expectations. Operations Night Order Book entries were made to explain* the surveillance requirement and a procedure revision to enhance/clarify the surveillance interval. All Licensed personnel and select Technical Department personnel, will review these events to ensure their understanding of the surveillance,interval. During the present re-qualification cycle, all licensed personnel will receive

  • training specific to these events. By 2/28/95~ additional procedure enhancement will be made to provide more focus on TS requirements and address human factors tied to procedure performance and review.

NRC FORM 366 (5*92)

e REQUIRED NUM~ER OF DIGITS/CHARACTE.

FOR EACH BLOCK -

BLOCK NUMBER OF TITLE NUMBER DIGITS/CHARACTERS 1 UP TO 46 FACILITY NAME 8 TOTAL 2 DOCKET NUMBER 3 IN ADDITION TO 05000 3 VARIES PAGE NUMBER 4 UP TO 76 TITLE 6 TOTAL 5 EVENT DATE 2 PER BLOCK 7 TOTAL 2 FOR YEAR 6 LER NUMBER 3 FOR SEQUENTIAL NUMBER

_ 2 FOR REVISION NUMBER 6 TOTAL 7 REPORT DATE 2 PER BLOCK UP TO 18 - FACILITY NAME 8 OTHER FACILITIES INVOLVED 8 TOTAL - DOCKET NUMBER 3 IN ADDITION TO 05000 9 1 OPERATING MODE 10 3 POWER LEVEL 1

11 REQUIREMENTS OF 10 CFR CHECK BOX THAT APPLIES UP TO 50 FOR NAME 12 LICENSEE CONT ACT 14 FOR TELEPHONE CAUSE VARIES 2 FOR SYSTEM 13 4 FOR COMPONENT EACH COMPONENT FAILURE 4 FOR MANUFACTURER

' NPRDS VARIES 14 SUPPLEMENTAL REPORT EXPECTED CHECK BOX THAT APPLIES -

6 TOTAL 15 EXPECTED SUBMISSION DATE 2 PER BLOCK

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER* PAGE Unit 2 5000311 94-012-00 2 of 5 PLANT AND SYSTEM IDENTIFICATION:.

Westinghouse - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes are identified in the text as {xx}

IDENTIFICATION OF OCCURRENCES:

Calorimetric (Heat Balance) Calculations Not Performed Within The specif ~ed Surveillance Interval On Both Units '

. Event Dates: (Unit 2) 1/8/94, 7/5/94, 7/8/94, 9/12/94, and 10/13/94 (Unit 1) 2/26/94, 3/5/94, arid 9/2/94 Discovery Date: 10/13/94 Report Date:

  • 11/14/94 This report was initiated by Incident Report No.94-304.

DESCRIPTION OF OCCURRENCES:

At approximately 0951 ho~rs on October 12, 1994, the requirements of Technical Specification (TS) Tabl.e 4. 3-1, Item 2, for daily calibration of power range instrumentation {IG} when above 15% of RATED THERMAL POWER, were met through satisfactory completion of the caloriinetric (heat balance-) calculation.

At 0530 hours0.00613 days <br />0.147 hours <br />8.763227e-4 weeks <br />2.01665e-4 months <br /> on October 13, 1994, with reactor power at 100%, a controlled reactor shutdown, at 5% per hour, was begun in preparation for refueling outage 2R8. At approximately 2200 hours0.0255 days <br />0.611 hours <br />0.00364 weeks <br />8.371e-4 months <br /> (same day),

decrease to 15% power was achieved and, at 2244 hours0.026 days <br />0.623 hours <br />0.00371 weeks <br />8.53842e-4 months <br /> (same day), the Unit was placed in MODE 3 (HOT STANDBY). On October 13, 1994, the surveillance requirements of TS Table 4.3-1, Item 2, (including the maximum allowable extension per TS 4.0.2) were not met, due to failure to perform the once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> calibration of power range instrumentation. Event discovery occurred on October 14, 1994.

Investigation revealed other instances on both Units during 1994, where the surveillance requirements of TS Table 4.3-1 were performed beyond the allowable extension per TS 4.0.2: Unit 2 - January 8

  • (reactor power 98.8%), July 5 (reactor power 43.3%), July 8 (reactor power 72.7%), and September 12 (reactor power 93.8%) and Unit 1 -

February 26 (reactor power 70.6%), March 5 (99.0%) and September 2 (reactor power 39.9%)~ ,

.. LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating station DOCKET NUMBER LER NUMBER PAGE Unit 2 5000311 94-012-00 3 of 5 ANALYSIS OF OCCURRENCES:

TSs specify that the nuclear instrumentation system (NIS) power range calibration be performed at least once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, whenever rated thermal power (RTP) is greater than 15%. Procedure S2.RE-ST.ZZ-0001(Q), "CALORIMETRIC"CALCULATION", is used to complete this calibration. In addition, during Monday through Friday, the Technical Department assists the Operations Department in the performance of this procedure. The "DAILY ROUTINES" checklist log of Operations Directive Procedure, SC.OP-DD.ZZ-OD40(Z), "SHIFT ROUTINES", Step 5.16, specifies the time frame for surveillance performance as oaoo-1200 hours. In addition, the procedure description for Step 5.16 states "The interval between calorimetrics shall not exceed 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />".

  • On October 13, 1994, Unit 2 operated above 15% power for approximately six hours and 53 minutes beyond the maximum allowable extension for the required .NISpower range calibration. As such, approximately 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> transpired* between the prior NIS calibration and when RTP was 15%.

Other instances occurred on both Units where the maximum allowable extension for the required NIS power range calibration was exceeded; Unit' 2*- two hours, 55 minutes; five hours,* 25 minutes; six hours, 19 minutes; and eight hours, 14 minutes; and Unit 1 - two hours, 42 minutes; 9 minutes; and three hours.

APPARENT CAUSE OF OCCURRENCES:

These events are attributed to "Personnel Error", as classified in Appendix B of NUREG_-1022. The event of October 13, 1994 resulted from failure of the Nuclear Control Operator (NCO) to follow procedure [Step 5.16 of SC.OP-DD.ZZ-OD40(Z)] combined with failure of the Nuclear Shift Supervisor (NSS) to adequately review the completed shift routines. A contributor was focus upon activities related to the ongoing Unit power reduction and removal o~ the Unit from_service for the upcoming refueling outage. Another contributor was a common mis-perception that the surveillance interval was once per calendar day and that the surveillance could be delayed within the confines of a calendar day, until establishing a stable plant condition which would allow performance of the surveillance. Existence of this misperception is reinforced by discovery of the additional events where the surveillance was not completed with the required time period. Analysis of failed barriers indicates the personnel errors were the result of less than adequate knowledge and training. Thi?

was evidenced by the misunderstanding the once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> surveillance requirement.

1- ..

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION

  • Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 2 5000311 94-012-00 4 of 5 PREVIOUS OCCURRENCES:

Previous events involving the.failure to perform the required daily NIS calibration occurred on December 8, 15, 16, and 26, 1977. These were identified as an.infraction in a Notice of Violation in NRC Inspection Report 50-272/78-02, dated February 17, 1978. The cause of these occurrences was attributed to ongoing Unit load transients,

  • which did not permit the required stable conditions to.allow*

completion of the surveillance. Corrective action included an Operations Night Order Book {NOB) entry on 1/28/78, instructing the Senior Nuclear Shift Supervisor {SNSS) of the necessity to perform the _surveillance. This NOB entry directed the SNSS to stop a load change, if required, to permit completion of the surveillanc.e within th_e required till\e frame.

SAFETY SIGNIFICANCE:

These events are reportable pursuant to 10CFR50.73{a) (2) (i) (B), due to failure to comply with the Limiting Condition For Operation requirements of TS Table 4.3-1, as well as TS 3.0.2, due to failure to perform the surveillance requirements within the.maximum allowable extension.

The safety signif i~ance of October 13 event is minimal as the approximate six hours 53 minutes the Unit operated until the requirements of TS no longer applied (i.e. entry into.MODE 3) is bounded by the requirements of TS 3.0.3.. The safety significance of the other occurrences is minimal based upon satisfactory completion of the surveillance following each event. In addition, in accordance with procedure, reaqtor power is maintained less than 100% and verified by an on-line calorimetric computer readout. The inputs to the on-line calorimetric computer readout are the same as the manual surveillance calculation.

CORRECTIVE ACTION:

All Licensed personnel involved in the October 13 event have been counseled concerning their *actions and Management expectations regarding procedure compliance.

An Operations NOB entry, explaining the surveillance requirement, was issued on.October 26, 1994.

SC.OP-DD.ZZ-OD40{Z) has been revised to enhance arid clarify the definition of. the surveillance interval. Additionally, a NOB entry was made on November 8, 199*4, describing the procedure change and requiring all Senior Shift Supervisors to review this change with their licensed personnel.

  • .e LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating station DOCKET NUMBER LER NUMBER PAGE Unit 2 5000311 94-012-00 5 of 5 CORRECTIVE ACTION: (cont'd)

As a result of these events, a review of all Operations TS surveillance requirements with frequencies of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> or less was performed to ensure TS compliance. This review identified four surveillances that, although presently adequate, will be procedurally enhanced as part of the SC.OP-DD.ZZ-OD40(Z) revision effort.

To ensure a clear understanding of the surveillance requirement, it has been specified, verbatim, in S1(2).RE-ST.ZZ-OOOl(Q). This procedure change has been discussed with select Technical Department personnel, who perform this requirement.

  • Based on interviews with involved personnel, Operations Management will revise SC.OP-DD.ZZ-OD40(Z), by February 28, 1995, to separate TS surveillance requirements from other routine evolutions. This change is intended.to provide more focus on TS requirements and-address human factors tied to performance and review of the procedure.

All Licensed personnel and select members of the Technical Department, will review these events to ensure their understanding of

  • the surveillance interval.

During the present re-qualification cycle, all licensed personnel will receive training specific to these events and TS surveillance interval requirements. Additionally, the Training Department will review the initial ~icensing Program -to ensure proper focus on TS interval requirements. The aforementioned training and review will encompass both Salem and Hope Creek programs.

MJPJ:pc SORC Mtg.94-087