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{{#Wiki_filter:~ ~ | {{#Wiki_filter:~ ~ | ||
p i- ,s-l e | p i- ,s-l e I j | ||
I j | |||
! U.601551 ; | ! U.601551 ; | ||
L45 89(11 01).LP ; | |||
l, 2C.220 l | |||
l, | |||
2C.220 l | |||
'llLIN019 POWER COMPANV ! | 'llLIN019 POWER COMPANV ! | ||
l1P CtlNTON POnM $TATaON, P.o. BOE 676. CLINTON. ILLINOt$ 01727 r | l1P CtlNTON POnM $TATaON, P.o. BOE 676. CLINTON. ILLINOt$ 01727 r | ||
November 1, 1989 n | |||
November 1, 1989 | P i 10CFR50,73 j L ; | ||
10CFR50,73 j L ; | |||
I Docket No. 50 461 | I Docket No. 50 461 | ||
( | ( | ||
U.S. Nuclear Regulatory Commissinn l Document Control Desk | U.S. Nuclear Regulatory Commissinn l Document Control Desk | ||
* Wshington, D.C. 20555 i | * Wshington, D.C. 20555 i | ||
==Subject:== | ==Subject:== | ||
Clinton Power Station . Unit 1 ., | Clinton Power Station . Unit 1 ., | ||
Licensee Eventlecort No. 89@i,QQ | Licensee Eventlecort No. 89@i,QQ | ||
'~ ' | '~ ' | ||
l | l | ||
==Dear Sir:== | ==Dear Sir:== | ||
Tlease find enclosed 1Acenree Event Report No, 89-034 00: | Tlease find enclosed 1Acenree Event Report No, 89-034 00: | ||
Lack of. Training. Personnel Irror'and Inadecuagg Con.munieggiqng,.) Ray 3 , | Lack of. Training. Personnel Irror'and Inadecuagg Con.munieggiqng,.) Ray 3 , | ||
,(n Failure to Verify Precess Radj,gri.on.. Monitor Ooerobility and to Meet [ | ,(n Failure to Verify Precess Radj,gri.on.. Monitor Ooerobility and to Meet [ | ||
Iechnical Soecification Recuirements, This report is being submitted in ! | Iechnical Soecification Recuirements, This report is being submitted in ! | ||
accordance with the requirements of 10CT1tSO.73. ; | accordance with the requirements of 10CT1tSO.73. ; | ||
Sincerely yours, 5 ). W D. L. Holtzscher Acting Manager . - | Sincerely yours, 5 ). W D. L. Holtzscher Acting Manager . - | ||
Licensing and Safety TSA/kra ; | Licensing and Safety TSA/kra ; | ||
: ' Enclosure [ | : ' Enclosure [ | ||
L , | L , | ||
Line 72: | Line 50: | ||
Illinois Department of Nuclear Safety NRC Clinton Licensing Project Manager i | Illinois Department of Nuclear Safety NRC Clinton Licensing Project Manager i | ||
fg# , | fg# , | ||
8911000044 891101 | 8911000044 891101 q, PDR ADOCK 05000461 g S PDC | ||
q, PDR ADOCK 05000461 g S PDC | |||
E 1 i | E 1 i | ||
e eenc pee. ans * | e eenc pee. ans * | ||
* v 6 Ettom Lt.uteou towussiow | * v 6 Ettom Lt.uteou towussiow | ||
, , Arenovao owe no neouw | , , Arenovao owe no neouw LICENSEE EVENT REPORT (LER) 8 " N'' S ' '8'" l l | ||
enciury e.amt m oocast wometa m ' ' M ' 3' Clinton Power Station 0 l6 t o l010 !4 l611 1 lOFl0 l 5 tittl e.. L.a C K 01 Training, fctsonnel Error and Inadequate Communications Result in Failure to trify Process Radiation Monitor Operability and to Meet Technical Specification Requirements eve =i cats m tea muusin m urou can m ot in eaceution swvotveo m ; | |||
LICENSEE EVENT REPORT (LER) 8 " N'' S ' '8'" l l | |||
enciury e.amt m oocast wometa m ' ' M ' 3' Clinton Power Station 0 l6 t o l010 !4 l611 1 lOFl0 l 5 tittl e.. L.a C K 01 Training, fctsonnel Error and Inadequate Communications Result in Failure to | |||
trify Process Radiation Monitor Operability and to Meet Technical Specification Requirements eve =i cats m tea muusin m | |||
urou can m ot in eaceution swvotveo m ; | |||
mowva oav vsan vaan "g '4 , | mowva oav vsan vaan "g '4 , | ||
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,aj,7,y' wowin oav vaan eac m iv nawis pocaat wome+aisi | |||
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,,,,,,,,,,, tuis ueone es eveuittio evneva=, to rne movinewswu o, u cen t re . . .,, ,. ., w ,i nu m'* 1 so .osm n am oo nmmo.i n ,u.i | ,,,,,,,,,,, tuis ueone es eveuittio evneva=, to rne movinewswu o, u cen t re . . .,, ,. ., w ,i nu m'* 1 so .osm n am oo nmmo.i n ,u.i y _ | ||
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: 90. 06teimlW X n.tateinfHil to.734eHtHei44Hal Je6dJ | : 90. 06teimlW X n.tateinfHil to.734eHtHei44Hal Je6dJ j , | ||
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Line 117: | Line 73: | ||
90 06 m m m De.n6selM to vata 4 thel | 90 06 m m m De.n6selM to vata 4 thel | ||
, tiCIN< co41kgGR eMiB 4th (13, _ _ | , tiCIN< co41kgGR eMiB 4th (13, _ _ | ||
e,1wt la LEPMD*.4 %M8t'l | e,1wt la LEPMD*.4 %M8t'l aMa co04 | ||
aMa co04 | |||
..D. W. Hiller, Director a Pir.nt P.adiation Protection, ent. 3313 ,,lil? | ..D. W. Hiller, Director a Pir.nt P.adiation Protection, ent. 3313 ,,lil? | ||
CMitt?( 044 tent f or tac,4 coma & twt .altVM of tealpto seg tM*3 setPon? H3) | CMitt?( 044 tent f or tac,4 coma & twt .altVM of tealpto seg tM*3 setPon? H3) 913151-13.J.81811 , | ||
913151-13.J.81811 , | |||
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caws nmu cwo*pa "t3l;;c- f' ; ewo=oa l's'M' csus hmi ";)';f Toi,''y s ,;, . | caws nmu cwo*pa "t3l;;c- f' ; ewo=oa l's'M' csus hmi ";)';f Toi,''y s ,;, . | ||
.b I I I I f 1 1 " i._l J l 1 l L..l_ __ | .b I I I I f 1 1 " i._l J l 1 l L..l_ __ | ||
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_ ,_. .v,3i w u n,c.t .. mon _,_, | _ ,_. .v,3i w u n,c.t .. mon _,_, | ||
Line 153: | Line 92: | ||
{ | { | ||
; On October 4, 1989, a Radiation Protection Shift Supervisor (RPSS) u discovered that the in service Station Heating, Ventilatinh and Air Conditioning (HVAC) Exhaust Stack Process Radiation Monitor (PRM), | ; On October 4, 1989, a Radiation Protection Shift Supervisor (RPSS) u discovered that the in service Station Heating, Ventilatinh and Air Conditioning (HVAC) Exhaust Stack Process Radiation Monitor (PRM), | ||
j ORIX PR001 had not been verified as operable. This resulted in a failure l to meet the Limiting Condition for Operation for Technical Specification l (TS) 3.3.7.12. This TS requires that one Station HVAC Exhaust Stack PRM i be operable at all times. At 0826 hours, PRM ORIX PR002 was removed from | j ORIX PR001 had not been verified as operable. This resulted in a failure l to meet the Limiting Condition for Operation for Technical Specification l (TS) 3.3.7.12. This TS requires that one Station HVAC Exhaust Stack PRM i be operable at all times. At 0826 hours, PRM ORIX PR002 was removed from service and PRM ORIX PR001 was placed in service. The Radiation , | ||
service and PRM ORIX PR001 was placed in service. The Radiation , | |||
1 Protection (RP) technician (tech) transferring the monitors did not perform all of the checks required to verify that PRM ORIX PR001 was , | 1 Protection (RP) technician (tech) transferring the monitors did not perform all of the checks required to verify that PRM ORIX PR001 was , | ||
operable after piccing it in service. Specifically, the RP tech performed a channel check on the monitor but did not verify flow. | operable after piccing it in service. Specifically, the RP tech performed a channel check on the monitor but did not verify flow. | ||
Line 162: | Line 99: | ||
=c . . m. - | =c . . m. - | ||
L 83) | L 83) | ||
r | r | ||
=,,c ..:., m. . | =,,c ..:., m. . | ||
u s =veau mumon, coMumm | u s =veau mumon, coMumm | ||
. , LICENSEE EVENT CEPORT (LER) TEXT C!NTINUATION eenovio oue un mo-e* , | . , LICENSEE EVENT CEPORT (LER) TEXT C!NTINUATION eenovio oue un mo-e* , | ||
som swa > | som swa > | ||
Line 175: | Line 109: | ||
013l4 ~ | 013l4 ~ | ||
0 10 0 l2 0F 0 l5 no. . e me,mmn { | 0 10 0 l2 0F 0 l5 no. . e me,mmn { | ||
DESCRIPTION OF EVENI I On October 4, 1989, t.he plant was in Mode 1 (POWER OPERATION) and the reactor [RCT) was at eighty five percent power. On the morning of October 4, 1989, Chemistry personnel contacted the Rad!ation Protection , | DESCRIPTION OF EVENI I On October 4, 1989, t.he plant was in Mode 1 (POWER OPERATION) and the reactor [RCT) was at eighty five percent power. On the morning of October 4, 1989, Chemistry personnel contacted the Rad!ation Protection , | ||
(RP) technician assigned as the Area / Process Radiation Monitor (AR/PR) l operator and requested that Radiation Protection personnel remove the in-service Station Heating, Ventilation, and Air Conditioning (HVAC) Exhaust Stack Process Radiation Monitor (PRM) [IL), ORIX PR002, from service and place the redundant monitor [ MON), ORIX PR001, in service. This monitor ; | (RP) technician assigned as the Area / Process Radiation Monitor (AR/PR) l operator and requested that Radiation Protection personnel remove the in-service Station Heating, Ventilation, and Air Conditioning (HVAC) Exhaust Stack Process Radiation Monitor (PRM) [IL), ORIX PR002, from service and place the redundant monitor [ MON), ORIX PR001, in service. This monitor ; | ||
transfer is performed weekly to ensure the monitors are used equally and | transfer is performed weekly to ensure the monitors are used equally and to enable Chemistry personnel to replace the ffiters (FLT) in the ; | ||
to enable Chemistry personnel to replace the ffiters (FLT) in the ; | |||
monitors in accordance with Technias,1 Sp9eification Table 4.3.7.12 1. , | monitors in accordance with Technias,1 Sp9eification Table 4.3.7.12 1. , | ||
The technician assigned as the AR,'PR operator had rot previeur',y , | The technician assigned as the AR,'PR operator had rot previeur',y , | ||
Line 187: | Line 118: | ||
ORIX PR002 from service ano placing it in "starJbya and the et.hodology. | ORIX PR002 from service ano placing it in "starJbya and the et.hodology. | ||
for placing redundmot monitor ORIX PR001 in service ('' normal") . The RTSS directed the technician to note the coepletion of the honLter exchange in i the RP log. The exchange van cogleted at 0826 hours. After completing the exchange, the RP techn! clan performt,d s channel [CHA) check on monitor ORIX PR001 by comparing its indication with the last indication of inonitor ORIX PR002. This check verified that monitor ORIX PR001 was in service and was providing accurate data to the Central Control Terminal (CCT) in the RP office. | for placing redundmot monitor ORIX PR001 in service ('' normal") . The RTSS directed the technician to note the coepletion of the honLter exchange in i the RP log. The exchange van cogleted at 0826 hours. After completing the exchange, the RP techn! clan performt,d s channel [CHA) check on monitor ORIX PR001 by comparing its indication with the last indication of inonitor ORIX PR002. This check verified that monitor ORIX PR001 was in service and was providing accurate data to the Central Control Terminal (CCT) in the RP office. | ||
At 1944 hours, during review of completed surveillance procedure 9911.24, "AR/PR Shiftly/ Daily Surve111ances", the second shift RPSS noted that not all checks required to verify operability of monitor ORIX PR001 were , | At 1944 hours, during review of completed surveillance procedure 9911.24, "AR/PR Shiftly/ Daily Surve111ances", the second shift RPSS noted that not all checks required to verify operability of monitor ORIX PR001 were , | ||
doc'iment ed. : | doc'iment ed. : | ||
Line 199: | Line 129: | ||
r . ) | r . ) | ||
i eene e.4 seea .' u s. tuctan c 6:vt .1ony ocmwnesioen j | i eene e.4 seea .' u s. tuctan c 6:vt .1ony ocmwnesioen j | ||
"" UCENSEE EVENT REPORT (LERI TEXT C;NTINUATION | "" UCENSEE EVENT REPORT (LERI TEXT C;NTINUATION A*eaovie ous wo wa-eita l (EPiftL& $'31/88 j j f ACILif t HAM 4 Hi (g aty wpupgn m 6th 6t h 461 tm @ | ||
A*eaovie ous wo wa-eita l (EPiftL& $'31/88 j j f ACILif t HAM 4 Hi (g aty wpupgn m 6th 6t h 461 tm @ | |||
"a* " STM." - | "a* " STM." - | ||
"'A*,47 Clinton Power Station o 15 lo j o l0 l4 [6 l1 8l9 - | "'A*,47 Clinton Power Station o 15 lo j o l0 l4 [6 l1 8l9 - | ||
Line 207: | Line 135: | ||
0l0 0l3 0F 0l5 ; | 0l0 0l3 0F 0l5 ; | ||
nxtc . 4 mci.e,assr.nm , | nxtc . 4 mci.e,assr.nm , | ||
t Technical Specification 3.3.7.12 permits a Station INAC Exhaust Stack PRM to be placed in an inoperable status for up to one hour for the purpose . | |||
t | |||
Technical Specification 3.3.7.12 permits a Station INAC Exhaust Stack PRM to be placed in an inoperable status for up to one hour for the purpose . | |||
of performing sutveillances. Monitor ORIX PR001 was placed in service at i 0826 hours, therefore the LCO for Technical Specification 3.3.7.12 was not met from 0926 hours until 2000 hours on October 4, 1989. | of performing sutveillances. Monitor ORIX PR001 was placed in service at i 0826 hours, therefore the LCO for Technical Specification 3.3.7.12 was not met from 0926 hours until 2000 hours on October 4, 1989. | ||
Ne automatic or manually initiated safety system responses were necersary to place the plant in a safe and stable condition. No other eyvipent o; conponents were inoperabic at the start of this event such that their , | Ne automatic or manually initiated safety system responses were necersary to place the plant in a safe and stable condition. No other eyvipent o; conponents were inoperabic at the start of this event such that their , | ||
Line 222: | Line 146: | ||
Contributing to the failure to meet the LCO for Technical Specification 3.3.7.12 was the lack of involvement of the RPSS in the monitor transfer process. The RPSS was aware that the monitor transfer was to occur because the evolution had been discussed at the Operations shift I | Contributing to the failure to meet the LCO for Technical Specification 3.3.7.12 was the lack of involvement of the RPSS in the monitor transfer process. The RPSS was aware that the monitor transfer was to occur because the evolution had been discussed at the Operations shift I | ||
turnover. However, the RPSS did not discuss the monitor transfer with RP l | turnover. However, the RPSS did not discuss the monitor transfer with RP l | ||
personnel at the RP shift turnover. The RPSS did not follow up to ensure | personnel at the RP shift turnover. The RPSS did not follow up to ensure the monitor transfer had been completed satisfactorily. | ||
the monitor transfer had been completed satisfactorily. | |||
In addition to performing AR/PR operator duties, the RP technician was acting as the on duty RP office technician performing routine RP office work. The RP technician was required to perform the additional duties because of the high volume of routine RP office work required to be performed in the first few hours of each shif t. Performing the duties of l | In addition to performing AR/PR operator duties, the RP technician was acting as the on duty RP office technician performing routine RP office work. The RP technician was required to perform the additional duties because of the high volume of routine RP office work required to be performed in the first few hours of each shif t. Performing the duties of l | ||
NRC V4M 366A *W,$. CPOs 190$.$20499 00070 C SM | NRC V4M 366A *W,$. CPOs 190$.$20499 00070 C SM | ||
y t | y t | ||
~ | ~ | ||
.e . . n.. . u a uvetto neumohuoMMissio= | .e . . n.. . u a uvetto neumohuoMMissio= | ||
. LICENSEE EVENT EEPORT (LER) TEXT CONTINUATION u+nono ove No. mo-oios | . LICENSEE EVENT EEPORT (LER) TEXT CONTINUATION u+nono ove No. mo-oios | ||
(*NAtt 411/89 | (*NAtt 411/89 | ||
Line 242: | Line 162: | ||
service, all of the checks required to verify operability may not have been performed. Procedure 7410.75 did not address the requirement to , | service, all of the checks required to verify operability may not have been performed. Procedure 7410.75 did not address the requirement to , | ||
perform surveillance 9911.24 when placing AR/PR monitors in service. | perform surveillance 9911.24 when placing AR/PR monitors in service. | ||
Procedure 7410.75 did not require that the Operatiene Shif t Supervisy r t e notified of monitor operability onu. the AR/PR monitors reyttired te acet a | Procedure 7410.75 did not require that the Operatiene Shif t Supervisy r t e notified of monitor operability onu. the AR/PR monitors reyttired te acet a | ||
Technical Specifications were placed in service. Operationa petronnel ' | Technical Specifications were placed in service. Operationa petronnel ' | ||
Line 249: | Line 168: | ||
RP pers onnel stated tt'at monitor ORIX PR001 was operating properly , i checks required to meet the requirements of Technical Specification 3.3.7.12 had been completed with aatisfactory rvsults. | RP pers onnel stated tt'at monitor ORIX PR001 was operating properly , i checks required to meet the requirements of Technical Specification 3.3.7.12 had been completed with aatisfactory rvsults. | ||
G,RRECTIVE ACTIQNf3 Radiation Protection Shift Supervisors have been counselled on the need I to ensure that RP technicians are fully qualified for the positions to , | G,RRECTIVE ACTIQNf3 Radiation Protection Shift Supervisors have been counselled on the need I to ensure that RP technicians are fully qualified for the positions to , | ||
which they are assigned. The Radiation Protection Shift Supervisors were also ceunselled on the need to review the Daily Activity Schedule for | which they are assigned. The Radiation Protection Shift Supervisors were also ceunselled on the need to review the Daily Activity Schedule for upcoming activities which involve or affect Radiation Protection, and on the need to discuss the status of these activities at the RP shift turnover meetings. , | ||
upcoming activities which involve or affect Radiation Protection, and on the need to discuss the status of these activities at the RP shift turnover meetings. , | |||
A night order was issued to appropriate Radiation Protection personnel regarding: the need to use procedures, particularly when placing monitors in service from a " standby" condition; the checks required to be performed in accordance with surveillance 9911.24; and the requirement to ' | A night order was issued to appropriate Radiation Protection personnel regarding: the need to use procedures, particularly when placing monitors in service from a " standby" condition; the checks required to be performed in accordance with surveillance 9911.24; and the requirement to ' | ||
notify Operations personnel when changing the status of monitors meeting Technical Specification requirements. | notify Operations personnel when changing the status of monitors meeting Technical Specification requirements. | ||
A night order was issued reminding appropriate Radiation Protection personnel that whea assigned to a position it is their responsibility to ensure that they meet the requirements of that position prior to assuming any additional duties or positions. This ensures that requirements are met, while at the same time providing for flexibility and reassignment of I personnel. | A night order was issued reminding appropriate Radiation Protection personnel that whea assigned to a position it is their responsibility to ensure that they meet the requirements of that position prior to assuming any additional duties or positions. This ensures that requirements are met, while at the same time providing for flexibility and reassignment of I personnel. | ||
Proceduren 7410.75 and 9911.24 have been revised to include the steps required to be completed to verify AR/PR monitor operability, and to include a step requiring that operations personnel be notified when a monitor is placed in service and when surveillance procedure 9911.24 has | Proceduren 7410.75 and 9911.24 have been revised to include the steps required to be completed to verify AR/PR monitor operability, and to include a step requiring that operations personnel be notified when a monitor is placed in service and when surveillance procedure 9911.24 has been satisfactorily completed. | ||
been satisfactorily completed. | |||
j c;, C MLM De6A *U.S. CPOe 190$*S30=S89,00010 | j c;, C MLM De6A *U.S. CPOe 190$*S30=S89,00010 | ||
Line 263: | Line 178: | ||
) , | ) , | ||
?ne es a.. . vs aucaza muuvoav co=*imiA | ?ne es a.. . vs aucaza muuvoav co=*imiA | ||
**" | **" | ||
* l l ., | * l l ., | ||
Line 270: | Line 183: | ||
, l | , l | ||
; exeman s w a j i.c . . , , . .. . . . omii .v. .n a u . . ,,, ...i., 1 vs*a ' | ; exeman s w a j i.c . . , , . .. . . . omii .v. .n a u . . ,,, ...i., 1 vs*a ' | ||
i | i "tf.'.W 'l C:f* }'G Clinton Power Station f.KT ## n,we apose 4 #eeured, asse emesseist A*C #enn ,tA6A W 11h 0l5l0l0l0l4l6l1 8 19 - | ||
Clinton Power Station f.KT ## n,we apose 4 #eeured, asse emesseist A*C #enn ,tA6A W 11h 0l5l0l0l0l4l6l1 8 19 - | |||
0 l3 l4 - | 0 l3 l4 - | ||
0 l0 0 l5 0F 0l5 j q | 0 l0 0 l5 0F 0l5 j q | ||
Line 286: | Line 194: | ||
l roonitor vr.e placed 1,1 an operat,le status prioY to bi-ing dsclared 1 operable. The cause cf this event wars vague coinanications bacween ; | l roonitor vr.e placed 1,1 an operat,le status prioY to bi-ing dsclared 1 operable. The cause cf this event wars vague coinanications bacween ; | ||
Operations and Rad 16 tion Protection ;eis.onnel regarding whether the annitor was in "normala or " standby'. | Operations and Rad 16 tion Protection ;eis.onnel regarding whether the annitor was in "normala or " standby'. | ||
For further information regarding this event, contact D. W. Miller, Director Plant Radiation Protection, at (217) 935 8881, extension 3313. | For further information regarding this event, contact D. W. Miller, Director Plant Radiation Protection, at (217) 935 8881, extension 3313. | ||
I l | I l | ||
I b | |||
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I l | I l | ||
l i | l i | ||
1 ', | 1 ', | ||
t | t | ||
,#;C FKad 466A 'U.S. CP0s 1988 6J0* S89 0004 | ,#;C FKad 466A 'U.S. CP0s 1988 6J0* S89 0004 | ||
! COM _ _ _ _ . . _ , . . _ . . _ _ . .}} | ! COM _ _ _ _ . . _ , . . _ . . _ _ . .}} |
Latest revision as of 18:56, 18 February 2020
ML19325E584 | |
Person / Time | |
---|---|
Site: | Clinton ![]() |
Issue date: | 11/01/1989 |
From: | Holtzscher D, Miller D ILLINOIS POWER CO. |
To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
References | |
LER-89-034, LER-89-34, U-601551, NUDOCS 8911080044 | |
Download: ML19325E584 (6) | |
Text
~ ~
p i- ,s-l e I j
! U.601551 ;
L45 89(11 01).LP ;
l, 2C.220 l
'llLIN019 POWER COMPANV !
l1P CtlNTON POnM $TATaON, P.o. BOE 676. CLINTON. ILLINOt$ 01727 r
November 1, 1989 n
P i 10CFR50,73 j L ;
I Docket No. 50 461
(
U.S. Nuclear Regulatory Commissinn l Document Control Desk
- Wshington, D.C. 20555 i
Subject:
Clinton Power Station . Unit 1 .,
Licensee Eventlecort No. 89@i,QQ
'~ '
l
Dear Sir:
Tlease find enclosed 1Acenree Event Report No,89-034 00:
Lack of. Training. Personnel Irror'and Inadecuagg Con.munieggiqng,.) Ray 3 ,
,(n Failure to Verify Precess Radj,gri.on.. Monitor Ooerobility and to Meet [
Iechnical Soecification Recuirements, This report is being submitted in !
accordance with the requirements of 10CT1tSO.73. ;
Sincerely yours, 5 ). W D. L. Holtzscher Acting Manager . -
Licensing and Safety TSA/kra ;
- ' Enclosure [
L ,
l cc: NRC Resident Office !
L NRC Region III, Regional Administrator i INFO Records Center ;
Illinois Department of Nuclear Safety NRC Clinton Licensing Project Manager i
fg# ,
8911000044 891101 q, PDR ADOCK 05000461 g S PDC
E 1 i
e eenc pee. ans *
- v 6 Ettom Lt.uteou towussiow
, , Arenovao owe no neouw LICENSEE EVENT REPORT (LER) 8 " N S ' '8'" l l
enciury e.amt m oocast wometa m ' ' M ' 3' Clinton Power Station 0 l6 t o l010 !4 l611 1 lOFl0 l 5 tittl e.. L.a C K 01 Training, fctsonnel Error and Inadequate Communications Result in Failure to trify Process Radiation Monitor Operability and to Meet Technical Specification Requirements eve =i cats m tea muusin m urou can m ot in eaceution swvotveo m ;
mowva oav vsan vaan "g '4 ,
,aj,7,y' wowin oav vaan eac m iv nawis pocaat wome+aisi None 0 [6l0 l 0 l 0l l l
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- On October 4, 1989, a Radiation Protection Shift Supervisor (RPSS) u discovered that the in service Station Heating, Ventilatinh and Air Conditioning (HVAC) Exhaust Stack Process Radiation Monitor (PRM),
j ORIX PR001 had not been verified as operable. This resulted in a failure l to meet the Limiting Condition for Operation for Technical Specification l (TS) 3.3.7.12. This TS requires that one Station HVAC Exhaust Stack PRM i be operable at all times. At 0826 hours0.00956 days <br />0.229 hours <br />0.00137 weeks <br />3.14293e-4 months <br />, PRM ORIX PR002 was removed from service and PRM ORIX PR001 was placed in service. The Radiation ,
1 Protection (RP) technician (tech) transferring the monitors did not perform all of the checks required to verify that PRM ORIX PR001 was ,
operable after piccing it in service. Specifically, the RP tech performed a channel check on the monitor but did not verify flow.
Therefore, the PRM was inoperable. This event was caused by lack of training, personnel error and inadequate communications. The RP tech was not fully qualified and the RPSS failed to direct the RP tech to use applicable procedures when placing PRM ORIX FR001 in service. Corrective l actions include reminding appropriate RP personnel of the need to use and l follow procedures, and counselling RP Shift Supervisors on the need to ensure techs are qualified and on the need to review and status activit.ies affecting RP.
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DESCRIPTION OF EVENI I On October 4, 1989, t.he plant was in Mode 1 (POWER OPERATION) and the reactor [RCT) was at eighty five percent power. On the morning of October 4, 1989, Chemistry personnel contacted the Rad!ation Protection ,
(RP) technician assigned as the Area / Process Radiation Monitor (AR/PR) l operator and requested that Radiation Protection personnel remove the in-service Station Heating, Ventilation, and Air Conditioning (HVAC) Exhaust Stack Process Radiation Monitor (PRM) [IL), ORIX PR002, from service and place the redundant monitor [ MON), ORIX PR001, in service. This monitor ;
transfer is performed weekly to ensure the monitors are used equally and to enable Chemistry personnel to replace the ffiters (FLT) in the ;
monitors in accordance with Technias,1 Sp9eification Table 4.3.7.12 1. ,
The technician assigned as the AR,'PR operator had rot previeur',y ,
performod a monitor exchange and therefore requastod direut'on frosn the :
c'ay shif t 'u.diation Protectica Shif t Supetvisor (RPSP.,. The RPSS j explained to the technician the wethodology for removing monitor ,
ORIX PR002 from service ano placing it in "starJbya and the et.hodology.
for placing redundmot monitor ORIX PR001 in service ( normal") . The RTSS directed the technician to note the coepletion of the honLter exchange in i the RP log. The exchange van cogleted at 0826 hours0.00956 days <br />0.229 hours <br />0.00137 weeks <br />3.14293e-4 months <br />. After completing the exchange, the RP techn! clan performt,d s channel [CHA) check on monitor ORIX PR001 by comparing its indication with the last indication of inonitor ORIX PR002. This check verified that monitor ORIX PR001 was in service and was providing accurate data to the Central Control Terminal (CCT) in the RP office.
At 1944 hours0.0225 days <br />0.54 hours <br />0.00321 weeks <br />7.39692e-4 months <br />, during review of completed surveillance procedure 9911.24, "AR/PR Shiftly/ Daily Surve111ances", the second shift RPSS noted that not all checks required to verify operability of monitor ORIX PR001 were ,
doc'iment ed. :
The RPSS di'tected the second shift RP technician assigned as the AR/PR ,
operator to perform surveillance 9911.24 to verify that monitor ORIX. I PR001 was operable. In accordance with surveillance 9911.24, the RP technician performed a channel check and a sample flow indicator [FI) check. Surveillance 9911.24 was completed at 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> with i satisfactory results. (A communications check, which is required to be ,
performed once each shift, was documented as having been completed at '
0741 hours0.00858 days <br />0.206 hours <br />0.00123 weeks <br />2.819505e-4 months <br /> and 1555 hours0.018 days <br />0.432 hours <br />0.00257 weeks <br />5.916775e-4 months <br />.) 6 Since the checks to verify the operability of monitor ORIX PR001 were not performed within one hour of placing monitor ORIX PR001 in service, the Limiting Condition for Operation (LCO) for Technical Specification 3.3.7.12 was not met. Technical Specification 3.3.7.12 requires that one station HVAC exhaust PRM be operable at all times. Operability of ORIX.
PR001 was not verified until 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> on October 4, 1989, 1
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t Technical Specification 3.3.7.12 permits a Station INAC Exhaust Stack PRM to be placed in an inoperable status for up to one hour for the purpose .
of performing sutveillances. Monitor ORIX PR001 was placed in service at i 0826 hours0.00956 days <br />0.229 hours <br />0.00137 weeks <br />3.14293e-4 months <br />, therefore the LCO for Technical Specification 3.3.7.12 was not met from 0926 hours0.0107 days <br />0.257 hours <br />0.00153 weeks <br />3.52343e-4 months <br /> until 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> on October 4, 1989.
Ne automatic or manually initiated safety system responses were necersary to place the plant in a safe and stable condition. No other eyvipent o; conponents were inoperabic at the start of this event such that their ,
inoperable condition contributed to this event. l 2 disl Ol' Eff.EI.
The cause of the event is attmibuted to inck of training, personnel artor and inadequatc comtaunications, g Tha RP technician assigned as the AR/PR operator was not fully qualified
, I. for that posit 3on becauce he had not completed all of the required training. He was horever, considered to have sufficient experience and to have demonstrated a level of proficiency sufficient to perform AR/PR i
operator activit.as under the direct supervision of fully qualified personnel.
i The RPSS failed to direct the RP technician to use the procedures governing the operation and testing of the AR/PR monitors when removing monitor ORIX PR002 from service and placing monitor ORIX PR001 in service. Radiation Protection procedure 7410.75, ' Operation of Digital AR/PR Monitors" provides instructions for removing monitors from service, for starting monitors, and for returning monitors to serrice.
Surveillance procedure 9911.24 provides instructions for performing the checks required to verify monitor operability. Neither of these procedures was utilized when transferring the Station INAC Exhaust Stack PRMs and verifying their operability.
Contributing to the failure to meet the LCO for Technical Specification 3.3.7.12 was the lack of involvement of the RPSS in the monitor transfer process. The RPSS was aware that the monitor transfer was to occur because the evolution had been discussed at the Operations shift I
turnover. However, the RPSS did not discuss the monitor transfer with RP l
personnel at the RP shift turnover. The RPSS did not follow up to ensure the monitor transfer had been completed satisfactorily.
In addition to performing AR/PR operator duties, the RP technician was acting as the on duty RP office technician performing routine RP office work. The RP technician was required to perform the additional duties because of the high volume of routine RP office work required to be performed in the first few hours of each shif t. Performing the duties of l
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both positions adversely affected the RP technician's performance of his AR/PR operator duties.
Procedure 7410.75 was reviewed following the event and it was determined that even if the applicable proceditres had been used when removing monitor OR1X PR002 from service and placing monitor ORIX PR001 in '
service, all of the checks required to verify operability may not have been performed. Procedure 7410.75 did not address the requirement to ,
perform surveillance 9911.24 when placing AR/PR monitors in service.
Procedure 7410.75 did not require that the Operatiene Shif t Supervisy r t e notified of monitor operability onu. the AR/PR monitors reyttired te acet a
Technical Specifications were placed in service. Operationa petronnel '
were natified that n.onitor ORIX PR001 was placed in service and that. the ,
monitor was op3 rating properly. Operations personnel believed that when -
RP pers onnel stated tt'at monitor ORIX PR001 was operating properly , i checks required to meet the requirements of Technical Specification 3.3.7.12 had been completed with aatisfactory rvsults.
G,RRECTIVE ACTIQNf3 Radiation Protection Shift Supervisors have been counselled on the need I to ensure that RP technicians are fully qualified for the positions to ,
which they are assigned. The Radiation Protection Shift Supervisors were also ceunselled on the need to review the Daily Activity Schedule for upcoming activities which involve or affect Radiation Protection, and on the need to discuss the status of these activities at the RP shift turnover meetings. ,
A night order was issued to appropriate Radiation Protection personnel regarding: the need to use procedures, particularly when placing monitors in service from a " standby" condition; the checks required to be performed in accordance with surveillance 9911.24; and the requirement to '
notify Operations personnel when changing the status of monitors meeting Technical Specification requirements.
A night order was issued reminding appropriate Radiation Protection personnel that whea assigned to a position it is their responsibility to ensure that they meet the requirements of that position prior to assuming any additional duties or positions. This ensures that requirements are met, while at the same time providing for flexibility and reassignment of I personnel.
Proceduren 7410.75 and 9911.24 have been revised to include the steps required to be completed to verify AR/PR monitor operability, and to include a step requiring that operations personnel be notified when a monitor is placed in service and when surveillance procedure 9911.24 has been satisfactorily completed.
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i ANALYSIS OF EVENT This event is reportable in accordance with the provisions of ;
10CFR50.73(a)(2)(1)(B) due to operation prohibited by Technical I i
Specifications. The 140 for Technical Specification 3.3.7.12 was not met from 0926 hours0.0107 days <br />0.257 hours <br />0.00153 weeks <br />3.52343e-4 months <br /> until 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> on October 4, 1989.
Aasessment of the nuclear safety consequences and inp11 cations of this i event indicated that this event was not safety significant for existing ,
or other p?. ant conditions. Cumpletion of survet11ance 9911.24 with satisfactory results indies.tes thet.sonitor ORIX.P3001 ess a.ccurately monitoring effluent through the Common HVAC Stack, e&D.LT12ML 1NNP. MAT 10N l
',, liu 88 020 00 discusse(. ttn failure to ensure that a liquid efaturnt .
l roonitor vr.e placed 1,1 an operat,le status prioY to bi-ing dsclared 1 operable. The cause cf this event wars vague coinanications bacween ;
Operations and Rad 16 tion Protection ;eis.onnel regarding whether the annitor was in "normala or " standby'.
For further information regarding this event, contact D. W. Miller, Director Plant Radiation Protection, at (217) 935 8881, extension 3313.
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