ML17227A719

LER 93-001-00:on 930108,chemistry Technician Failed to Sample Third SI Tank & Sampling of SI Tank 2A1 Not Performed within TS Required Interval After Filling Tank.Caused by Personnel Error.Personnel counseled.W/930205 Ltr

ML17227A719
Person / Time
Site:	Saint Lucie
Issue date:	02/05/1993
From:	Hurchalla J, Sager D FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-93-30, LER-93-001-01, LER-93-1-1, NUDOCS 9302110293
Download: ML17227A719 (5)

Text

ACCEI ER D DOCUMENT DIS IBVTION SYSTEM REGUL RY INFORMATION DISTRIBUT SYSTEM (RIDS)ACCESSION NBR:9302110293 DOC.DATE: 93/02/05 NOTARIZED:

NO FACIL:50-389 St.Lucie Plant, Unit 2, Florida Power&Light Co.AUTH.NAME AUTHOR AFFILIATION HURCHALLA,J.A.

Florida Power E Light Co.SAGER,D.A.

-Florida Power 6 Light Co.RECIP.NAME RECIPIENT AFFILIATION DOCKET 05000389

SUBJECT:

LER 93-001-00:on 930108,chemistry technician failed to sample third SI tank 6 sampling of SI tank 2A1 not performed within TS required interval after filling tank.Caused by personnel error.Personnel counseled.W/930205 ltr.DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR g ENCL g SIZE: TITLE: 50.73/50.9 Licensee Event Report (LER)-, Incident Rpt, etc.NOTES: RECiPIENT ID CODE/NAME PD2-2 LA NORRIS,J INTERNAL: ACNW AEOD/DOA.AEOD/ROAB/DSP NRR/DLPQ/LHFB10 NRR/DOEA/OEAB NRR/DST/SELB 8D NR~SPLB8Dl REG FILE 02 GN2~LE 01 EXTERNAL: EGErG BRYCE,J.H NRC PDR NSIC POORE,W.COPIES LTTR ENCL 1 1 1 1 2 2 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 RECIPIENT ID CODE/NAME PD2-2 PD ACRS AEOD/DSP/TPAB NRR/DET/EMEB 7E NRR/DLPQ/LPEB10 NRR/DREP/PRPB11 NRR/DST/SICB8H3 NRR/DST/SRXB 8E RES/DSIR/EIB L ST LOBBY WARD NSIC MURPHY,G.A NUDOCS FULL TXT COPIES LTTR ENCL 1-1 2 2 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 R NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.504-2065)TO ELIMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!L S FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 31 ENCL 31 P.O.Box 128, Ft.Pierce, FL 3o954-0128 February 5, 1993 L-'93-30 10 CFR 50.73 U.S.Nuclear Regulatory Commission Attn: Document Control Desk Washington, D.C.20555 Re: St.Lucie Unit 2 Docket No.50-389 Reportable Event: 93-001 Date of Event: January 8, 1993 Missed Surveillance for Safety In ection Tank Sam lin Due to Personnel Error The attached Licensee Event Report is being submitted pursuant to the requirements of 10 CFR 50.73 to provide notification of the subject event.Very truly yours, D.A.S Vice P St.Lu ger sident e Plant DAS/JWH/kw Attachment cc: Stewart D.Ebneter, Regional Administrator, USNRC Region II.Senior Resident, Inspector, USNRC, St.Lucie Plant DAS/PSL N857-93 3.00042 9302110293 930205 PDR ADOCK 050003B9 8 PDR an FPL Group company~/gJ I FPL Fscsirriis oi NRC Form S68 (e.es)V S.NLCL EAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)APPITCYT 0 CNS ISA$1 50 010l EXP'.l 1500 t EST NEED NATCE N 005 PESPONSE To COWL Y WITH THE PPOISAATION COL LEC TON INOLEST150 ll 550$, TONWAAO CONMENTS PECAIEANO 55505tH 5STNAA TE TO TIE PECOPOSANC INPCTTTSIIANAOENENT TTLFNCH(P~LLS, IACLENLINQAATOIY CONLPSSCFL WANANCTCN.

CC t05NL AIO TO THE PAPENFICFIA FETACTCN PNCVECT Ol 50 010PA CF 5 IcE oF NANAEE LENT No NAxft.wASFNIOTIPL oc t05NL FACILITY NAME (1)DOCKET NUMBER (2)St.Lucie Unit 2 A 050003891 0 3 T'TLE{)Missed Surveillance for Safety Injection Tank Sampling Due to Personnel Error EVENT DATE (5)LER NUMBER (6)REPORT DATE (7)OTHER FACILITIES INVOLVED (8)0 1 DAY 0 8 YEAR 9 3 YEAR 9 3 ,.'IAL 0 0 1 gR 0 0 0 2 DAY YEAR 0 5 9 3 FACILITY NAMES N/A N/A DOCKET NUMBER(S)050 0 05000 OPERATING MODE (9)POWER LEVEL (10)1 0 0;Cgjl r 20.402(b)20.405(a)(1)(i) 20.405(c)50.36(c)(1) 20A05(a)(1)(II) 50.36(c)(2) 20.405(a)(1)(iii) 20.405(a)(1)(iv) 20.405(a)(1)(v) 50.73(a)(2)(I)50.73(a)(2)(ii) 50.73(a)(2)(iii)LICENSEE CONTACT FOR THIS LER 12 50.73(a)(2)(iv) 50.73(a){2){v) 50.73(a)(2)(vii) 50.73(a)(2)(viii)(A) 50.73(a)(2)(viii)(B) 50.73(a)(2)(x)

THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR: Check one or more of the followin, (11)73.71(b)73;71{c)OTHER (Specify in Abstract below and in Text NRC Form 366A)NAME James A.Hurchalla, Shift Technical Advisor TELEP ONE NUMBER AREACODE 4 0 7 465-3550 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13 CAUSE SYSTEM COMPONENT REPORTABLE TO NPRDS SYSTEM COMPONENT MANUFAC REPORTABLE TURER TO NPRDS SUPPLEMENTAL REPORT EXPECTED 14 YES (If yes, complete EXPECTED SUBMISSION DATE)X NO I I I EXPECTED MONTH DAY YEAR SUBMISSION DATE (15)ABSTRACT'(Limit to 1400 spaces.i.e.

approximately fifteen single-space typewritten lines)(16)On January 8, at 0500 a Reactor Control Operator (RCO)filled the 2A1, 2A2, and 2B2 Safety tnjection Tanks'SITs) and subsequently notified Chemistry.

A Chemistry technician sampted two of the SITs per the required surveillance but faited to sample the third.On January 8,1993, at 2300 the Unit 2 Assistant Nuclear Plant Supervisor discovered that the sampling of the 2A1 Safety Injection Tank had not been performed by Chemistry within the required time interval atter filling the tank.Using, the 25%maximum allowable extension permitted by.Technical Specification (TS)4.0.2, the latest time at which the sampling could have been performed on time was January 8, at 1230.The root cause of the event was personnel error by a Chemistry technician responsible for the sampling.When informed by Operations that specific SITs have been filled it is the responsibility of the Chemistry department personnel on shift to sample these SITs for the required boron concentration per TS 4.5.1.1.b.

In addition, there was a failure on the part of the control room personnel to realize that one of the three filled SITs had not been sampled when Chemistry notified them that two SITs were within specification.

Corrective actions were;1)Perform the 2A1 SIT sutveiltance.

2)Create a status board by which Chemistry can insure that the appropriate SITs have been sampled.3)The Chemistry personnel involved were counselled.

4)Operations personnel have been counselled.

5)A Human Performance Evaluation System evaluation was subsequently conducted whose findings agree with this report.FPL Facsimile of NRC Form 366 (6-89)

PPL PSCSIITTle Ot NRC FOTm&OSl6 89)U.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)TEXT CONTINUATlON

'APPROITOCAAT KLSITCSIPA l splpaa ACGIT TSTPAATTOIMICTNPTRRTSPONSl TOOOINTTWITH TIPSPPOISAAOCNCOIlf CTON RTOUT ST I ISA IPTS IORNNO CCANRNT 0 RTGARTNIC TAPSXN TSTINATl TOPIC RTCORCS AICI IS PORTS N ANAGT AS NT SRANCH TP 000A U 0, IAICI 0 AIT Rl OIAA TORY OAA+CSSN70 WANTNCTON,OCT000S NAPTOTIR PAPTRWOPNRTOVCTIONPRORCTI'TIICCISPAOIIICC OP NANAK NTNT AM)TANCTT.WAN SNCTOIA OC PPNO FACILITY NAME (1)St.Lucie Unit 2 DOCKET NUMBER (2)YEAR EQUENTIAL NUMBER."T',." REVISION vl NUMBER LER NUMBER (6)PAGE (3)0 500 0389 TEXT (If more spaceis reqoired, tjse additional NRC Form 366A's)(17)9 3 0 0 0 0 0 2 0 3 Operations fills Safety Injection Tanks (SIT)(EIIS:

BP)as necessary to maintain the required Technical Specification (TS)level.Subsequently these SITs must be sampled in accordance with-Chemistry Operating Procedure 2-C-60 within 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> to ensure that the required TS boron concentration has been maintained.

On January 8, 1993, at 0500 a Reactor Control Operator (RCO)filled the 2A1, 2A2, and 2B2 SITs.At 0530 he notified the onshift Chemistry technician.

The Chemistry technician who received the call turned the sampling responsibility over to an oncoming technician on the next shift.This technician received the appropriate verbal instructions of which SITs to check but only sampled the 2A2 and 2B2 SITs.At 0830 he notified the control room that these SITs were satisfactory wilh respect to boron concentration.

Operations personnel received the call and failed to notice that one of the SITs had not been sampled.At 2314 the oncoming Assistant Nuclear Plant Supervisor was reviewing the RCO chronological log and discovered the 2A1 SIT had not been sampled.The SIT was administratively declared out of service and Chemistry was notified to sample it.The sample showed satisfactory boron concentration and the 2A1 SIT was declared back in service at 2345.V The root cause of the event is cognitive personnel error by a utility Chemistry technician by failing to ensure the sampling of the appropriate SITs.A contributing factor is that there was no method other than verbal request turnover between Chemistry technicians to insure that the correct SITs are sampled.This places the full responsibility for the correctness and timeliness of this TS surveillance on verbal communication with no recorded information for the Chemistry technician to reference.

In addition, there was a failure on the part of control room personnel to realize that one of the three SITs had not been sampled when Chemistry notified them that two SITs were within specification.

There were no unusual characteristics of the work location which contributed to this event.T V This event is reportable under 10 CFR 50.73.a.2.i.b, as a missed surveillance required by Technical Specifications.

Technical Specification 4.5.1.1.b states that each Safety Injection Tank shall be demonstrated operable within 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> after each solution volume increase greater than or equal to 1%of tank volume by verifying the boron concentration of the solution.The purpose of this sampling is to provide assurance that the boron concentration of the SITs has not been changed to a value-outside the band of the Technical Specification requirements.

This assures that the assumptions used for the SITs in the Final Updated Safety Analysis Report (FUSAR)are valid.The surveillance of the 2A1 SIT was completed at 2340, or 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> and 40 minutes past the required Technical Specification sample time.FPL Facsimile of NRC Form 366 (6-89)

F PL Facsimro ot r NRC Form 666 (669t.U.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)TEXT CONTINUATlON APPAOVTOCallNCI 0ll00IOI 000TIES.0000 0 00TAAATTO nvexNPT frfE0PONTE ToCOAWlvvATN TI0000aNAAOONCcuTCTEPI IEOIE 00 I 000 0000 f CTIWATEr CCANE NT 0 IE CAN ONC TAPCTN 00TINAT K To OE TE COII0 Ala fEPTNTCNANACTAENTCPlANCNIP0000ua IAcTTArl TEaAATONT~

WASHNC TON, OC 00000 APAT To TIE 0 APT frWONA TE COCTION PNOE C'0 fll 00 0 I Ol 0 0Ãf ICT Of NANACTIENT AIO TANCET.WACIIAOT000 OC 00NO.FACILITY NAME{1)St.LUCie Unit 2 DOCKET NUMBER (2)YEAR LER NUMBER{6)EQUENTIAL NUMBER REVISION NUMBER PAGE (3)0 500 0389 9 3 TEXT (If more spaceis required, use additional NRC Form 366A's)(17)0 0 1 0 0 0 3 0 0 3 The results of the chemistry sample showed the boron concentration to be within Technical Specification 3.5.1.c.The 2A1 Safety Injection Tank was capable of performing its intended safety function as set forth in the assumptions of the FUSAR, sections 6.3.2.2.1 and 6.3.3.4.3.f.

TI;erefore, lhe health and safety of the public was not affected by this event.1)The 2A1 Safety Injection Tank (SIT)Chemistry Surveillance was performed with satisfactory results January 8, 1993 at 2340 hours0.0271 days <br />0.65 hours <br />0.00387 weeks <br />8.9037e-4 months <br />.2)The Chemistry department now uses a status board to track regulatory required surveillances that are not periodically scheduled..

3)The personnel involved in this event have been counselled by the Chemistry supervisor on the importance of meeting surveillance requirements.

-4)The Operations supervisor has issued a Night Order on this event which emphasizes the need for operators to track surveillances such as the one described in the LER via the operator turnover sheet, and the need for the oncoming crews to carefully review the chronological log.5)A Human Performance Enhancement System (HPES)evaluation was performed.

The results agree with the conclusions of this Licensee Event Report.ITI NA F n n F il There were no component failures involved in this event.VI A previous similar event is described in LER 389-89-008, which describes a missed surveillance for Safety Injection Loop Header valves following the filling of two SITs.FPL Facsimile of NRC Form 366 (6.89)