ML17261A450

LER 87-002-00:on 870306,RCS Oxygen Analysis Indicated That Steady State Requirements of Tech Spec 3.1.6.2 Had Been Exceeded.Caused by Personnel Error & Procedural Inadequacy. Procedural Guidance Being developed.W/870405 Ltr

ML17261A450
Person / Time
Site:	Ginna
Issue date:	04/05/1987
From:	Filkins D, Kober R ROCHESTER GAS & ELECTRIC CORP.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-87-002, LER-87-2, NUDOCS 8704130520
Download: ML17261A450 (9)

Text

REGULATORY FORMATION DISTR IBUTI ON SY M (R IDS)ACCESSION NBR: 8704130520 DOC.DATE: 87/04/05 NOTARIZED:

NO FACIL: 50-244 Robert Emmet Qinna Nuclear Plant>Unit 1>Rochester G AUTH.NAME AUTHOR AFFILIATION FILKINSs D.L.-Roch ester Qas 5 El ectr i c Corp.KOBERi R.W.Rochester Gas Sc Electric Corp.RECIP.NAME.RECIPIENT AFFILIATION DOCKET 0 05000244

SUBJECT:

LER 87-002-00:

on 87030&i RCS oxygen analysis indicated th"t steady state requirements ow Tech Spec 3.i.h.2 had been exceeded.Caused by personnel error Zc procedural inadequacy.

Procedural guidance being developed.

W/870405 ltr.DISTRIBUTION CODE: IE22D COPIES RECEIVED: LTR ENCL SIZE: TITLE: 50.73 Licensee Event Report (LER)i Incident Rpt>etc.NOTES: License Exp date in accordance with 10CFR2>2.109<9/19/72).

05000244 RECIPIENT ID CODE/NAME PD1-3 LA STAHLEi C INTERNAL: ACRS MICHELSON ACRS NYLIE AEOD/DSP/ROAB NRR/ADT NRR/DEST/ADS NRR/DEST/ELB NRR/DEST/MEB NRR/DEBT/PSB NRR/DEST/SQB NRR/DLPG/GAB NRR/DREP/EPB i/PMAS RB EQ 02 RQN1 FILE 01 EXTERNAL: EQRQ QROH>M LPDR NSIC HARRIS J COPIES LTTR ENCL 1 1 1 1 1 1 2 2 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 5 1 1 1 1 RECIPIENT ID CODE/NAME PD1-3 PD ACRS MOELLER AEOD/DOA AEOD/DSP/TAPB NRR/DEST/ADE NRR/DEST/CEB NRR/DEST/ICSB NRR/DEST/MTB NRR/DEST/RSB NRR/DLPG/HFB NRR/DOEA/EAB NRR/DREP/RAB NRR/PMAS/PTSB RES SPEISi T H ST LOBBY NARD NRC PDR NSIC MAYSi G COPIES LTTR ENCL 1'1 1 1 1 1 1 0 1 1 1 1 1-1 1 1 1 1 1 1 1 1 1 1 1 1 1 TOTAL NUMBER OF COPIES REQUIRED: LTTR 41 ENCL 39 HrIC Form$OO 10421 LICENSEE EVENT REPORT ILERI U.S.NUCLEAR REOVLATORY COMMISSION AFFROU EO OMS HO.$190W10a KXFIRKS: Sn)ISS FACILITY NAME (Il'.E.Ginna Nuclear Power Plant oocxtT IavMsth l21 o s o o,o 244>o(:07 RtFORT OATS (1)Lth HUMSKR (I)OOCXKT HVMSKRISI p s 0 0 0 EVENT OATS IS)MONTH OAY YEAR FACII,ITV H*MOS OTHER FACILIT)tt IHVOLYEO (SI YEAR rravraaarr rrvMo~R OAY a a 0 v a rr a I A L y?g HVMOSR MONTH YEAR Reactor Coolant System Oxygen Concentration Exceeds Technical'pecification Limits Due-To Personnel Error and Procedural Inade a'.;.0 306 87 8 7 002 0 0 0 4 0 5 8 7 O 50 0 ()OFSRATIHO MOOS (Sl~OIYKR p p p 1101 20.402(S I 20.OCS(a)(11(0 20 a004)(ll(tl 20.409(a l(litt)I 20A00 4)ill~()el 20.400(al (Illa)20.a00(al SOM(al (I)90.$9(~)(2)90.2$4)al(0 SO.T$41121(~I 90.22(a)12)(SO LICENSE t CONTACT FOR THIS Lth lit)SO,2$4 I(2)I Iv)SO.2$4)(2)(el 90.2241(21 (et)SO.T$4)121(aOI)

I A I 90.2$(~I(21(rat)(S) 90.2$la)12)(a)THIS REFORT IS SUSMITTEO FURSUANT T O THE REOUlhtlatNTS OF 10 CFR$r (Cooers orro rN moro oI rara Iotorerrrgl (11 TS.TIW 2$.7((a)OTHKR Itooaloy M Aoroeat aaron arro Io I'aat, Nhc Fomr$SMI NAME r Duane L.Filkins, Manager, Health Physics and Chemistry TELKFHOHK NUMSER AREA COOK 31 55 24-44 46 COMFLSTS ONK LINK I'OR EACH COMFOH KNT FAILURE OtSCRISKO IH THIS RtFORT l12)CAUSE SYS'EM COMFOHKNT MANUFAC TUNER EFORTASLE TO NFROS R~%A'F CAVSE SYSTEM COMFONENT MAHVFAG TUNER KFORTASL TO HOROS%VI SUFFLKMKNTAL RtFORT tXFKCTtO I)al YES Ill Far, oomo)eri EXPECTED SVSMI$$ION OA TET HO AKKTRAcT (Lamia Io f400 a)racer.l.o.ooororarratery htrearr arroroeoeao ryarerrrrnNr lkroal (1 9)EXFECT'EO SUSMISSION OATS II SI MONTH OAY YEAR.During startup from a refueling outage on March 6, 1987, at 0009 EST, a reactor coolant system (RCS)oxygen analysis indicated that t: he steady state requirements of Technical Specification (TS)3.1.6.2 had been exceeded.A review of the previous days analytical results indicated a-previous analysis on March 5, 1987, had indicated a similar result which violated the 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> limiting condition for operation in TS 3.1.6.4.A reactor coolant system cooldown was initiated to lover system temperature and to allow addition of hydrazine to scavenge oxygen from the system.The cause for exceeding the TS requirements was personnel error and procedural inadequacy.

There was no procedural guidance in the operating procedures which correlates required chemistry sampling to RCS tempera-ture.The technician did not initially recognize that TS requirements had been exceeded.To preclude recurrence better procedural guidance is being developed and technician training will be performed based on this LER.There were no significant safety consequences of this incident.870413052 05000244 0 87040>PgR AgoC'K pgR S~HRC'Fern$90~~*~.c~(9021 wi NAC Perer SSSA (9 891 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION U.S, NUCLEAA AEOULATOAY COMMISSION APPROVEO OMS NO.SI SOW(04 EX~INES: 8(SI(85 I'ACILITY NAME (ll R.E.Ginna Nuclear Power Plant TEXT (If rrrere Nrece Ir reeeeee, we cere(lre(Hr(C ferrrr JSSA Yl (Ill OOCXET NUMSEI((SI o s o o o 244 LEII NUMEEI(ISI YEAN.p)8 SSOUSNTIAL PrÃeeyrSION NUM Trl rer rrUM ee 7-002-0~AOE (SI 2oF 07 I.PRE-EVENT PLANT CONDITIONS On March 4, 1987, the unit was starting up from the annual refueling and maintenance outage.On this date the plant left the cold shutdown condition and heated up to approximately 315 F, 350 psig reactor coolant system (RCS)temperature and pressure, respectively, to perform steam generator (S/G)crevice cleaning per operating procedure.0-10.The TS requirements for RCS oxygen of less than 0.1 ppm had been achieved prior to increasing RCS temperature above 200oF.II.DESCRIPTION OF EVENT A.EVENT On March 6, 1987, at 0009 EST with S/G crevice cleaning in progress, a RCS sample was taken as required by Attachment I of procedure PC-1.1 (Primary System Analysis Schedule and Limits).This procedure outlines the required analysis and limits for RCS chemistry during hot shutdown and normal operation.

The result of the oxygen analysis of the above sample was 0.5 ppm.The plant technician performing the analysis recognized this result a6 a number greater than allowed by TS for the existing plant conditions.

As is routine, a confirming sample was taken and an oxygen analysis performed at 0130 EST with the same result.A review of the plant technicians laboratory notebook revealed that on March 5, 1987 at 0030 EST, another sample and analysis had been performed which also indicated oxygen concentration in the RCS greater than 0.1 ppm.The Ginna Station TS, Section 3.1.6.2, requires that corrective action be taken immediately when the normal steady state RCS oxygen concentration limit of 0.1 ppm is exceeded.Also TS Section 3.1.6.4 requires that if the normal steady state limits for RCS oxygen are exceeded-and cannot be returned to within the limits within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, the reactor shall be brought to the cold shutdown condition.

Because, from 0030 EST on March 5, 1987, until 0235 EST on March 6, 1987, (a lapsed time of approximately 26 hours3.009259e-4 days <br />0.00722 hours <br />4.298942e-5 weeks <br />9.893e-6 months <br />), the RCS oxygen concen-tration exceeded its normal steady state limit with no corrective action taken, both sections of TS, 3.1.6.2 and 3.1.6.4 were exceeded.B.INOPERABLE STRUCTURES, COMPONENTS OR SYSTEMS THAT CONTRIBUTED TO THE EVENT: None rr (9 81 I NRC Fmw JTSA l9 SJI LICENSEE EVENT REPORT (LER)TEXT CONTINUATION V.S.NVCLKAR RSOVLATORY COMMISSION APP ROY 5 0 0 MS NO, J I 50&I di SXPIRTSS/JI/95 FACILITY NAMS Ill R.E.Ginna Nuclear Power Plant: TTJT IIT race epoCP II leeAwd.Pae~NIIC fOne JTSAJI 0T)OOCKKT NVMJSR IJI o o o o o 4 4 LTR NVMJSR ISI YSAR~X, STCUTNTIAL:

N ATY>SUN N MTTR.'i~F NUM TR 87 002 0~AOI IJI 03 ap07 C.DATES AND APPROXIMATE TIMES FOR MAJOR OCCURRENCES:-

o March 4, 1987, 0900 EST: Unit leaves cold shutdown, RCS.oxygen concentration less than 0.1 ppm.o March 5, 1987, 0030 EST: Event date.o March 6, 1987, 0009 EST: Discovery date.o March 6, 1987, 0130 EST: Confirmatory.

sample taken.o March 6, 1987, 0235 EST: Plant cooldown initiated.

N o March 6, 1987, 0800 EST: RCS average temperature less than 250oF.o March 6, 1987, 1030 EST: RCS oxygen concentration within TS requirements.

D.OTHER SYSTEMS OR SECONDARY FUNCTIONS AFFECTED: None E.METHOD OF DISCOVERY:

The event was made apparent during the foreman's review of the plant technicians laboratory notebook.F.OPERATOR ACTION: The plant technician reported the event to the Control Room.The Control Room operators initiated a plant cooldown per TS requirements at 0235 EST on March 6, 1987.By 0800 EST the RCS average temperature was less than 250 F.At 0935 a hydrazine addition was made to the RCS which brought the oxygen concentration within TS requirements by 1030 EST.SAFETY SYSTEM RESPONSES:

None k'f7D lAell l95JI NRC Sarra SSSA (9 85)LICENSEE EVENT REPORT ILER)TEXT CONTINUATION U.S.NUCLEAR REOULAIORY COMMISSION AP/rROV EO OMS NO.5150&l0e EXelRES.8/Sl/85 aACILITY NAME (II R.E.Ginna Nuclear Power Plant T EXT///mare eaece/e/rr/rerL eee e~AlRC/rarm 8(/SA'e/I I TI III.CAUSE Op EVENT OOCKET NUMSER (ll o s o o o 244 LER NUMSER (SI SEQUENT/*L l),)IYIS 0 Nvv 8 I~~r/UMSKA 7 0 2 0 0 eACE (sI 04 pFO 7 A.IMMEDIATE CAUSE: RCS oxygen concentration was greater than the normal steady state TS limit for more than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> with no immediate corrective action taken.This was due partially to a cognitive error since the technician failed to recognize that the analytical results exceeded the TS requirements for the RCS temperature which existed at the time.It was also partially the result of a procedural inadequacy since there was no procedural guidance in the operating procedure which correlated required chemistry sampling to RCS temperature.

B.ROOT CAUSE: The results of a root cause investigation determined that there were two maj or.root causes that contributed to the event.These are as follows: The Health Physics and Chemistry section failed to recognize the RCS oxygen concentration was exceeding TS requirements for approximately 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.This occurred because of the following reasons and actions: o The crevice cleaning operating procedure holds the RCS temperature between cold shutdown and hot shutdown for extended periods of time.0 The plant chemistry procedure, PC-1.1, only provided a schedule for analysis for the following plant conditions:

0 a.Hot shutdown or normal operation, Attachment I b.Cold shutdown, Attachment II c.Refueling shutdown, Attachment III On March 5, 1987, Attachment II was in use, which did not require a RCS oxygen analysis be taken.The technician who performed the oxygen analysis on this date had received a verbal request from another technician to run the RCS oxygen analysis with no apparent reason given.Since the analysis was not required, he did not, recognize the significance of the results.NRC eORM 888*t9 85 I NRC lorna 844A I9 8SILICENSEE EVENT REPORT ILER)TEXT CONTINUATION V.S.NUCLEAR REOULATORY COMMISSION ATPROYEO OM8 NO.SISOMI04 EXPIRES: 8ISII8$tACILITY NAME III R.E.Ginna Nuclear Power Plant OOCKET NUMEER ISI LER NUMEER l4l YEAR,'8@slQUENTIAL gP ntvataon NUMttll..r NUMttn TACE ISI TEXT lit moro Naoco*rotarooe'.

ooo oOtrnrnaM HRC rranrn 848A'rI IITI o s o o o 2 4 8 7, 0 0 2 0'0'5 QF 0 7.0 The analytical results for RCS chemistryare normally.entered into the Primary System Chemistry Log and also on the Daily Chemistry Analysis Results Form which is forwarded to Operations daily.The chemistry results obtained on March 5, 1987, were not entered on either of these records.Supervisory reviewL of the chemistry log did not recognize the lack of results for March.5, 1987, until March 6, 1987, and Operations also did not recognize the lack of results for March 5, 1987.Although the review of these logs would not have precluded exceeding the requiremegts o f TS 3.1.6.2, it is likely that corrective action would haye been taken prior to exceeding 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> if the results had been properly logged.2.The unanticipated oxygen concentration increase in the RCS.This happened because of the following reasons and actions: o The investigation of the cause of the oxygen increase in the RCS revealed that the step.in procedure 0-10 which requires burping of the volume control tank (VCT)with hydrogen had been marked non-applicable'(N/A);

This is allowed-procedurally.

and Operations had been directed by the outage planning group to proceed with only a nitrogen overpressure on the VCT.This had been done in the 1985 and 1986 outages without oxygen excursions, so this was not without precedent.

The reason for not introducing hydrogen is to allow a more rapid turnaround if system leaks should develop during performance of the primary system hydro.If the hydrogen concentration is increased in the RCS, operating procedures require removal prior to system drain down to preclude possible explosive mixtures in primary components.

This is a time consuming process.0 Without hydrogen to control oxygen, any source of oxygen would cause increases in the RCS oxygen concentration.

Three sources that could have contributed to the oxygen ingress to the RCS were: a.The volume control tank was not burped so any oxygen in the tank would have been allowed to come into equilibrium with the RCS.a a'a I9 8SI NRC iona$48A 19 881 LICENSEE EVENT REPORT{LER)TEXT CONTINUATION V.S, NUCLEAR REOVLATORY COMMISSION APPROVED OME NO.S($0&(08 EXPIRES: 8/SI/8$PACILIEY NAME lll R.E.Ginna Nuclear Power Plant DOCKET'VMEER (EI LER NVMEER (81 YEAR@'80vENT/AL

$8)aov/Sion NUMPEN~a NVM oa SEXY///naao NN(o/o~, ooo o////oao/HRC AN/a 80848 I (11(o s o o o 24487 00 0 0 6 ov 0'7 b.c~Normal introduction of reactor make-up water would introduce oxygen into the RCS.Some oxygen would have been formed by radiolysis of water while passing through the core.IV.AN YSIS OF EVENT I Thih event is reportable in accordance with 10 CFR 50.73, Licensee Event Report System, Item (a)(2)(i)(B), which requires reporting of"any operation prohibited by the plant's Technical Specifi-cations>>in that the plant was in a degraded mode avowed'by the Technical Specifications for a period of time longer than that permitted by the Technical Specifications.

An assessment was performed of the safety consequences and impli-cations of the event with the following results and conclusions:

o The basis for control of oxygen in the RCS is to minimize general corrosion and to prevent localized stress corrosion in the presence of chloride and fluoride ions.During the period of time that the oxygen concentration was outside the operating band,.both the chloride and fluoride concentrations were well below the normal operating requirements.

o Since the oxygen concentrations never exceeded the TS transient limits (always 0.5 ppm or less)and the chloride and fluoride concentrations were within requirements, there would have been no anticipated degradation of RCS system components and, therefore, no safety consequences or implications from this event.V.CORRECTIVE ACTION A.ACTIONS TAKEN TO RETURN THE RCS OXYGEN CONCENTRATION TO NORMAL STEADY STATE OPERATING VALUES: o The RCS was cooled down to less than 250oF to allow the addition of hydrazine to scavenge the oxygen.o Hydrazine'as added to the RCS and oxygen was brought within TS limits.B.ACTIONS TAKEN OR PLANNED TO PREVENT RECURRENCE:

nl Rail a (8 4$1 0 Corrective action currently in progress will provide better procedural guidance to assure the Health Physics and Chemistry section is aware when the RCS temperature-has been increased and chemistry requirements have changed.

NIIC Pena 588A 19 831 LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLTAII IITOULATOIIY COMMISSION APPAOY8O OM8 NO.31$0WI05 8XPIA85" 8ITI/8$PACILITY NAM8 lll R.E.Ginna Nuclear Power Plant-OOCK8T NUM88II LTI LKII NUM88II 181 YTAA j>pI 55QUCNTIAL

&Ail eayl5%n ,c,.?NUM 8 P4'UM Te PA48 151 TtxT III<<eea apace la>>aakaf, a>>aaAveavl ryilc Pane 888A81 Illl o s o o o 24 487-002-0 07 DF07 o The Health Physics and Chemistry technicians involved with primary system chemistry have all been made aware of the errors which contributed to the event.o A copy of this LER will be forwarded to the Training section and will be.included in the training program for the Health Physics and Chemistry section.VI.ADDITIONAL INFORMATION A.FAILED COMPONENTS:

There were no component f ailures that contribgted to this event.B.PREVIOUS LERs ON SIMILAR EVENTS: A similar LER event historical search was conducted with the f oil owing results: no documentation of similar LER events could be identified.

N c 0 19 851

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a'C.5 April 5, 1987 U.S.Nuclear Regulatory Commission Document Control Desk Washington, DC 30555

Subject:

LER 87-002, Reactor Coolant System Oxygen Concentration Exceeds Technical Specification Limits Due to Personnel Error and Procedural Inadequacy R.E.Ginna Nuclear Power Plant Docket No.50-244 In accordance with 10 CFR 50.73, Licensee Event Report System/Item (a)(2)(i)(B) which requires a report of"any operation prohibited by the plant Technical Specifications", the attached Licensee Event Report LER 87-002 is hereby submitted.

~~V truly yours, xc: U.S.Nuclear Regulatory Commission Region I 631 Park Avenue King of Prussia, PA 19406 Ginna USNRC Resident Inspector Roger W.Kober