ML20005G295

LER 89-039-00:on 891212,operations Shift Supervisor Notified That Three HPCS Suction Valves Not Tested within Max Surveillance Time Interval.Caused by Personnel Error. Surveillance Procedure revised.W/900108 Ltr

ML20005G295
Person / Time
Site:	Clinton
Issue date:	01/08/1990
From:	Holtzscher D, Morris D ILLINOIS POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-039, LER-89-39, U-601584, NUDOCS 9001180394
Download: ML20005G295 (6)

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' /LLINDIS POWER COMPANY CLINTON PCMER STATION. P.O. BOX 678. CLINTON, ILLINOIS 61727 5 January 8, 1990 10CFR50.73 Docket No. 50-461 U.S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555

Subject:

Clinton Power Station -l Unit 1 Licensee Event Report No. 89-039-00

Dear Sir:

Please find enclosed Licensee Event Report No. 89-039-00:

Licensed Onerator Misinterpretinc a Note in a Surveillance Procedure Results in Failure to Demonstrate Operability of Hinh Pressure Core Sorav System Suction Valves. This report is being submitted in accordance with the requirements of 10CFR50.73.

Sincerely yours, b /WA D. L. Holtzscher Acting Manager - -i Licensing and Safety

!' RSF/krm Enclosure cc: NRC Resident Office NRC Region III, Regional Administrator INPO Records Center Illinois Department of Nuclear Safety NRC Clinton Licensing Project Manager I

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, APPROVED OMO NO. 2190410e LICENSEE EVENT REPORT (LER) 'ka's ersi m 81CILITY NAME (1) DOCEE T NUMBER (2) P AGE 63, ,

Clinton Power Station 0 l5 J 01010 l4 l 611 1 lOFl 015 Licensed Operator Misinterpreting a Note in a Surveillance Procedure Results in Failure to Demonstrate Operability of High Pressure Core Spray System Suction Valves EVENT DATE (61 LER NUMeER 461 REPORT DATE (71 OTHER F ACILITIES INVOLVED 15)

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NAME TELEPHONE NUMBER AREA CODE D. R. Morris, Director-Plant Operations, extension 3205 21117 91315I-I8l8f811 COMPLETE ONE LINE FOR EACH COMPONENT F AILURE DESCRISED IN TH18 REPORT (131

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On December 12, 1989, with the plant in HOT SHUTDOWN, the Operations Shift Supervisor (SS) was notified that three High Pressure Core Spray (HPCS) system suction valves had not been tested within the maximum surveillance time interval permitted by Technical Specification 4.0.2.b to demonstrate that the valves met operability requirements. In ,

response, the SS declared the three valves and the HPCS system inoperable and immediately initiated the surveillance test to verify operability of the three valves. The surveillance test was completed with satisfactory results. The cause of this event is attributed to a utility licensed operator misinterpreting a note in a surveillance procedure. This resulted in the Assistant Shift Supervisor marking the surveillance sections associated with the three valves as not applicable. Corrective action for this event includes revising appropriate surveillance procedures to delete the note that was misinterpreted, including a description of this event and the findings of the associated investigation in the Operations " night orders", briefing Operations shift crews on the importance of reviewing completed surveillance packages thoroughly and accurately to ensure that applicable requirements are met, and ensuring that. procedures are reviewed for problems such.as human factors concerns. i l

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DESCRIPTION OF EVENT on December 12, 1989, the plant was in Mode 3 (HOT SHUTDOWN), at 478  !

degrees Fahrenheit and 570 pounds per square inch gauge, and a planned maintenance outage was in progress. At 1405 hours0.0163 days <br />0.39 hours <br />0.00232 weeks <br />5.346025e-4 months <br />, the Operations Shift Supervisor was notified that three High Pressure Core Spray (HPCS) system (BG) suction valves [V) had not been tested within the maximum surveillance time interval permitted by Technical Specification 4.0.2.b-to demonstrate that the valves met operability requirements.

On November 3, 1989, surveillance procedure 9051.02, "High Pressure Core l Spray (HPCS) Valve Operability Test," was performed in accordance with j Technical Specifications 4.0.5 and 4.6.4.3 to obtain Inservice Inspection-(ISI) data. The Assistant Shift Supervisor incorrectly marked sections 8.1.2 through 8.1.6 of this surveillance as not applicable and, as a result, operators did not perform these sections. Procedure sections  ;

. 8.1.2 through 8.1.6 provide instructions for monthly stroke time testing l of valves 1E22-F001 and 1E22-F015, and for monthly verification of' the l torque value required to open the disc of check valve 1E22-F016. Since  !

these procedure sections were not performed, valves 1E22-F001, HPCS suction from the Reactor Core Isolation Cooling (RCIC) system (BN) storage tank [TK]; 1E22 F015, HPCS suction from the suppression pool; and l

1E22 F016 HPCS suppression pool suction check valve, were not tested'.

On December 3, 1989, at 1505 hours0.0174 days <br />0.418 hours <br />0.00249 weeks <br />5.726525e-4 months <br />, the surveillance interval including the allowable extension specified in Technical Specification 4.0.2.b expired for demonstrating operability of valves 1E22-F001, 1E22 F015, and 1E22-F016. The surveillance interval of this Technical Specification <

specifies that "the combined time interval for any three consecutive surveillance intervals shall not exceed 3.25 times the specified ,

surveillance interval." The failure to perform surveillance testing of I the three valves within the specified time interval constitutes a failure to meet the operability requirements,for the Limiting Condition for '

Operation.

On December 12, 1989, while reviewing ISI data compiled for November, the engineering ISI coordinator noted that test data for valves 1E22-F001, 1E22-F015, and 1E22-F016 had not been provided. The engineering ISI coordinator informed the operations surveillance coordinator that no data was provided for the three valves. The operations surveillance coordinator immediately notified the Operations Shift Supervisor that the three valves had not been tested.

On December 12, 1989, at 1405 hours0.0163 days <br />0.39 hours <br />0.00232 weeks <br />5.346025e-4 months <br />, the Operations Shift Supervisor declared valves 1E22-F001, 1E22-F015, and 1E22-F016, and the HPCS system-inoperable and immediately initiated surveillance 9051.02 to verify operability of the three valves. At 1603 hours0.0186 days <br />0.445 hours <br />0.00265 weeks <br />6.099415e-4 months <br />, the surveillance was completed with satisfactory results and the valves and the HPCS~ system were declared operable.

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0l0 0 l3 OF 0 l5 svi a mm ma n nene. a. ne-w ww rw nwonm No automatic or manually initiated safety system responses were necessary to place the plant in a safe and stable condition. No equipment or components were inoperable at the start of this event such that their inoperable condition contributed to this event.

CAUSE OF EVENT The cause of this event is attributed to a utility licensed operator misinterpreting a note that preceded section 8.1.1 of surveillance procedure 9051.02. This resulted in the Assistant Shift Supervisor marking applicable sections of surveillance 9051.02 as not applicable.

The note preceding section 8.1.1 of surveillance procedure 9051.02 .

indicates that section 8.1.1 is only performed in conjunction with  !

section 8.3 of surveillance procedure 9051.01, "HPCS System Pump Operability." Sections 8.2 and 8.3 of surveillance procedure 9051.01 each provide a different method for demonstrating HPCS pump operability and each provide instructions for testing different valves. Depending on which of these sections is used to demonstrate HPCS pump operability, section 8.1.1 of surveillance 9051.02 may or may not be applicable because the method of testing used in surveillance 9051.01 determines which valves must be tested in surveillance 9051.02.

On November 3, 1989, while preparing to perform surveillance 9051,02, the Assistant Shift Supervisor incorrectly interpreted the note which preceded section 8.1.1 as being applicable to all of section 8.1 of

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l surveillance 9051.02. Since Section 8.1.1 of surveillance procedure 1 9052.02 was not applicable to the surveillance performed on November 3, i l 1989, the Assistant Shift Supervisor marked all of section 8.1 (sections  !

8.1.1 through 8.1.6) as not applicable. Additionally, another Assistant Shift Supervisor who reviewed the completed surveillance 9051.02 did not I recognize that applicable sections of the surveillance were marked as not l applicable. l The formatting of procedure 9051.02, section 8.1, contributed to the 1

Assistant Shift Supervisor misinterpreting the note preceding section 8.1.1.

CORRECTIVE ACTION i

The Assistant Shif t Supervisor who caused this event understands his error in misinterpreting the note in procedure 9051.02; therefore, no specific corrective action was necessary with respect to this individual.

However, Operations shift crews will be briefed on the importance of f reviewing completed surveillance packages thoroughly and accurately to ensure that applicable requirements are met. This briefing is scheduled to be completed by January 29, 1990.

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IlRC Fum 364A U.S. NUCLE A3 C.EIULATORY COMMISE80N LICENSEE EVENT REPORT (LERI TEXT CONTINUATION unoveo oue no. 3 iso-oio4 EXPIRES: 0/31/8B F ACILi1Y NAMf. (H DOCRET WAISER (28 LER NUM8th (6) . PAGE (3) m.w

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Surveillance procedure 9051.02 will be revised to delete section 8.1.1 and the note preceding that section. Surveillance procedure 9051.01 will be revised to include the valve testing requirements from section 8.1.1 of procedure 9051.02. These revisions are scheduled to be completed by February 9, 1990, j

A description of this event and the findings of the investigation of this event were included in the Operations " night orders" on December 26, 1989, to emphasize to shift crews that closer attention must be given to ensure correct marking of procedure sections as not applicable.

Additionally, IP is taking actions to ensure that procedures are effectively reviewed for problems such as human factors concerns. IP is revising the CPS procedure writer's guide,. administrative procedure 1005.01, " Preparation, Review, Approval, and Implementation of and Adherence to Station Procedures and Documents", to incorporate applicable methodology and techniques obtained from the Institute of Nuclear Power Operations (INPO) procedure writer's guide and from procedure programs of other utilities identified by INPO as having good procedures. IP has also established a centralized procedure group consisting of various disciplines. This group is responsible for developing and revising procedures, performing biennial procedure reviews, and incorporating temporary procedure changes into plant staff procedures. This group will be trained on the use of the reviJed procedure writer's guide. Plant staff procedures will be reviewed for human factors concerns during the l normal revision process and during biennial reviews.

1 ANALYSIS OF EVENT This event is reportable under the provisions of 10CFR50.73(a)(2)(1)(B) because of the failure to meet the surveillance interval specified by Technical Specification 4.0.2.b.

The provisions of Technical Specification 4.0.2.b were not met from 1505 hours0.0174 days <br />0.418 hours <br />0.00249 weeks <br />5.726525e-4 months <br /> on December 3, 1989 to 1603 hours0.0186 days <br />0.445 hours <br />0.00265 weeks <br />6.099415e-4 months <br /> on De'cember 12, 1989.

l l Assessment of the nuclear safety consequences and implications of this event indicates that this event was not safety significant for existing

or other plant conditions. This assessment is based on the completion of-

! sections 8.1.2 through 8.1.6 with satisfactory results at 1603 hours0.0186 days <br />0.445 hours <br />0.00265 weeks <br />6.099415e-4 months <br /> on December 12, 1989.

ADDITIONAL INFORMATION l

l No components failed during this event.

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[ LERs89-015 00 and 88-031-00 discuss similar licensed operator errors involving the failure to implement surveillance procedure steps.

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