Text

LER 95-005-00:on 950705,failure to Analyze Second Sample W/ Radiation Monitor Inoperable Occurred.Caused by Personnel Error.Second Sample Analyzed & Determined to Be in Agreement W/First Sample
	ML18101A875
Person / Time
Site:	Salem
Issue date:	08/04/1995
From:	Suey G; Public Service Enterprise Group
To:	;
Shared Package
ML18101A873	List: ML18101A871; ML18101A875;
References
	LER-95-005-02, LER-95-5-2, NUDOCS 9508100198
	Download: ML18101A875 (6)
	v • d • e

NRC FORM 366 u. ~LEAR REGULATORY COMMISSION ED BY OMB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ES Tl MA TED 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, DC 20555-0001, AND TO THE PAPERWORK (See reverse for required number of digits/characters for each block)

REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (11 II DOCKET NUMBER (2) PAGE 131 SALEM GENERATING STATION, UNIT 2 0500031 1 1 OF 6 TITLE (4)

Technical Specification Violation: Failure to analvze second samole with Radiation Monitor lnooerable EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (B)

MONTH DAY YEAR YEAR SEQUENTIAL REVISION MONTH DAY YEAR FAOLITY NAME DOCKET NUMBER NUMBER NUMBER 05000 FACILITY NAME DOCKET NUMBER 07 05 95 95 -- 005 -- 00 08 04 95 05000

'~ THIS REPORT JS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check one or more) (11)

- (9)

~ 20.402(b) 20.405(c) 50. 73(a)(2)(iv) 73.71 (b)

POWER 20.405(a)( 1)(i) 50.36(c)(1) 50. 73(a)(2)(v) 73.71(c)

LEVEL (1) () Ofn 20.405(a)( 1)(ii) 50.36(c)(2) 50. 73(a)(2)(vii) OTHER

20.405(a)(1 )(iii) x 50. 73(a)(2)(i) (B) 50. 73(a)(2)(viii)(A) (Specify in Abstract 20.405(a)(1 )(iv) 50. 73(a)(2)(ii) 50.73(a)(2)(viii)(B) below and in Text,

!l!!llll!lll:l!!!llll!lll!ll*l!!!!!!!:11111111111111111111111111*111111111111111111!1*11111*1 20.405(a)(1 )(v) 50. 73(a)(2)(iii) 50. 73(a)(2)(x) NRC Form 366A)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER (Include Area Code)

G. Suey, Chemistry Manager (609) 339-2830 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (131

-

CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TO NPRDS TO NPRDS

- - -- -- -

I YES (If yes, complete EXPECTED SUBMISSION DATE).

SUPPLEMENTAL REPORT EXPECTED (14)

ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (161

- x1NO EXPECTED SUBMISSION DATE (15)

MONTH DAY YEAR On July 5, 1995 at approximately 0022 hours2.546296e-4 days 0.00611 hours 3.637566e-5 weeks 8.371e-6 months , a liquid release for 22 eves Monitoring Tank was initiated. The release evolution was completed at 0343 (same day) . Prior to the release, one liquid effluent monitor (2R18) had been inoperable (since 5/6/95) and Technical Specification (TS) Action statement (3.3.3.8, Action B) was entered. This TS Action requires, in part that "prior to initiating a release, at least two independent samples are analyzed. . . ,,

Prior to release, two independent samples were obtained from the monitoring tank. The first sample was analyzed for activity levels and manual release rate calculations were performed and independently verified. Release authorization was provided to Operations without analyzing and comparing the spectrum of the second sample with the first sample. This is in violation of the TS and procedure. Following the release, the technician advised the supervisor of the error on July 5, 1995 at approximately 0730 hours0.00845 days 0.203 hours 0.00121 weeks 2.77765e-4 months . The second sample was immediately analyzed and determined to be in agreement with the spectrum of the first sample. This event is attributed to personnel error. In addition, the procedures were enhanced to minimize the potential for human error. The Chemistry technician involved was disciplined and Chemistry department technicians were provided feedback and training.

NRC FORM 366 (5-92) 9508100198 950803 PDR ADOCK 05000311 S PDR

NRC FORM 366A CLEAR REGULATORY COMMISSION A VED 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 COMMENTS REGARDING BURDEN ES Tl MA TE TO THE LICENSEE EVENT REPORT (LER) INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, TEXT CONTINUATION WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION SALEM GENERATING STATION, UNIT 2 05000311 NUMBER NUMBER 2 OF 6

--005 -- 000 95 TEXT (If more space is required, use additional copies of NRC Form 366A) 117)

Plant and System Identification:

Westinghouse - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes and component function identifier codes appear in the text as {XX/XX}.

Identification of Occurrence Faiiure to analyze the second independent sample prior to releasing the contents of the Chemical Volume and Control System (CVCS) Monitoring Tank to the Service Water discharge header.

Event Date: July 5, 1995 Report Date July 2 6, 1995 This report was initiated by Incident Report No. 95-1065.

Conditions Prior to Occurrence:

Both Units were in a self-imposed extended shutdown Mode 5 Reactor Power % Unit Load Mwe Description of Occurrence On July 5, 1995 at approximately 0022 hours2.546296e-4 days 0.00611 hours 3.637566e-5 weeks 8.371e-6 months , a liquid release from the 22 CVCS Monitoring Tank (CVCSMT) {IL} was initiated. The release evolution was completed at 0343 (same day). Prior to the release, one liquid effluent monitor (2R18) had been inoperable (since 5/6/95) and Tech Spec Action statement (3.3.3.8, Action B) was entered. For one inoperable liquid effluent monitors, Tech Spec Action statement (3.3.3.8, Action B, Table 3.3-12, Note

26) requires, in part that "prior to initiating a release, at least two independent samples are analyzed ... ". Authorization for release of the tank contents was provided to Operations without analyzing and comparing the spectrum of the second sample with the first sample. Failure to perform the analysis of the second sample is in violation of the TS and procedure.

The CVCSMT stores the treated or low activity waste for analysis prior to discharging the waste through a monitored (2R18) line to the service water discharge header and then to the circulating water di~charge. The analysis determines the quantity of radioactivity, with an isotopic breakdown of the constituent radionuclides.

Radiation Monitor (RM) channel 2R18 continuously monitors liquid radwaste released from Salem Unit 2. If a radiation alarm setpoint is exceeded or a NRC FORM 366A (5-92)

NRC FORM 366A U. . CLEAR REGULATORY COMMISSION A ED 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 COMMENTS REGARDING BURDEN ESTIMATE TO THE LICENSEE EVENT REPORT (LER) INFORMATION ANO RECORDS MANAGEMENT BRANCH (MNBB 77141, U.S. NUCLEAR .REGULATORY COMMISSION, TEXT CONTINUATION WASHINGTON, DC 20555-0001, ANO TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (31 YEAR SEQUENTIAL REVISION SALEM GENERATING STATION, UNIT 2 05000311 NUMBER NUMBER

3 OF 6 95 005 -- 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (171 Description of Occurrence (Cont'd) monitor failure occurs, the channel initiates a closure signal to the 2WL51 valve thereby terminating the release in progress.

At the time of this event, the above RM was inoperable. Therefore, prior to initiating a release, two independent samples -were obtained from the monitoring tank in accordance with TS Action statement (3.3.3.8, Action B, Table 3. 3-12, Note 26) . The first sample was *analyzed by the Chemistry technician for activity levels. Manual r~lease rate calculations were performed and independently verified by two independent and technically qualified members of the facility staff. The analysis determined that the quantity of radioactivity was below the allowable technical specification limit for release. The second sample was not analyzed until after the release evolution was completed.

Analysis of Occurrence On July 4, 1~95 at 1303, Chemistry Technicians completed the addition of hydrogen peroxide to Unit One Reactor Coolant System for crud burst in accordance. with Procedure SC.CH-AD.RC-0413 (Q). The purpose of this is to solubilize crud for cleanup via demineralizers, thereby reducing radiation levels. Samples are required approximately one hour after addition and after each start and stop (bump) of the Reactor Coolant Pump. A second addition was made at 1420 and sampling commenced at 1520. Additional samples were taken at 1610, 1635, and 1710 following bumping of each Reactor Coolant Pump (RCP).

One other sample was taken during this shift at 2105.

At approximately 1730 (same day), the -Unit 2 Nuclear Shift Supervisor (NSS) called and inquired about the status of 22 Chemical Volume Control System Monitoring Tank (CVCSMT) release samples. The shift technician was-unaware of a pending need for a release from the. monitor tank. There was no turnover from the previous shift stating release samples were needed (the previous shift technician also was unaware a release was needed) . Once. alerted, the shift technician found the release request in the Primary Chemistry Laboratory. At 1750 two independent samples were obtained from 22 CVCSMT and analysis started at 1757.

The shift technician returned to the Primary Lab and continued working on crud burst sample analysis and data entry while the CVCSMT sample was counting.

The technician left the auxiliary building at approximately 1815 and returned shortly after 1830. Upon returning, .he went to the Counting Room and checked the results of 22 CVCSMT. He prepared the liquid release initiation form in accordance with procedure SC.CH-TI.ZZ-0189(R), and performed the manual release rate calculations for liquid effluents in.accordance with Form SC.CH-TI.ZZ-0189-3. He then forwarded the_ calculation to the other on-site NRC FORM 366A (5-921

NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION AP VED 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 COMMENTS REGARDING BURDEN ESTIMATE TO THE LICENSEE EVENT REPORT (LER) INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, TEXT CONTINUATION WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (11 DOCKET NUMBER (2) LER NUMBER (61 PAGE (3)

YEAR SEQUENTIAL . REVISION SALEM GENERATING STATION, UNIT 2 05000311 NUMBER NUMBER 4 OF 6 95 -- 005 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

Analysis of Occurren_ce (Cont'd) qualified chemistry technician to perform the second independent verification of the release rate calculations.

At approximately 1950, the on-call Chemi~try Supervisor was contacted at home by the shift

technician to give release approval to Operations Department.

The shift technician informed the supervisor that 2R18 RM was inoperable~ The other on site chemistry technician performed the independent verification of the manual calculation. The release contained a warning message requiring the technician to contact a Chemistry Supervisor before proceeding. The warning

. message stated "the release may exceed -projected quarterly dose criteria of T. s. 3. 11. 1. 3 and may require processing prior to release" . The Chemistry Supervisor discussed the technical specification with the technician. He asked the technician to verify the tank had been processed by the Boric Acid Evaporator or the Vendor Demineralizer/Filter. The technician reviewed procedure S2.0P-SO.WL-0002{Q) Attachment 2 page 1 of 12 and verified the tank had been processed. The Chemistry Supervisor provided written authorization for the release. Based on this written authorization, operations authorized and approved the release and the release evolution commenced.

The chemistry technician did not properly comply with all of the procedural requirements of SC.CH-TI.ZZ-0189(R). This procedure requires two independent samples be analyzed prior to initiation of a release.

On July 5, 1995 at approximately 0730, the shift technicians from July 4, 1995 informed the Counting Room Supervisor a mistake was made; the required second independent sample was not analyzed. The superV"isor contacted the Control Room to see if the release of 22 eves MT could be stopped, but was informed the release had already occurred. The second sample was immediately analyzed and determined to be in agreement with the spectrum of the first sample.

Apparent Cause of Occurrence The cause code classification "A", "personnel error" (per NUREG 1022) is attributed to this event. A contributing cause was determined to be self-imposed time pressure.

Prior Similar Occurrence There are no previous similar events associated. with the requirement to analyze the second independent sample prior to release.

Safety Significance This condition is reportable pursuant to 10CFR50. 73 (a) (2) (i) (B) due to the failure to completely satisfy Tec,hnical Specification Action Statement 3.3.3.B(b) "Radioactive Liquid Effluent Monitoring Instrumentation"(Table 3.3-NRC FORM 366A (5-92)

~cronM~

I L W-92)

U.

CLEAR REGULATORY COMMISSION A ED BY OMB NO. 3150-0104 EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE LICENSEE EVENT REPORT (LER) INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 77141, U.S.

NUCLEAR REGULATORY COMMISSION, TEXT CONTINUATION WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-01041, OFFICE OF .MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME 111 DOCKET NUMBER 12) LER NUMBER 161 PAGE 131 YEAR SEQUENTIAL REVISION SALEM GENERATING STATION, UNIT 2 05000311 NUMBER NUMBER 5 OF 6 95 005 00 TEXT (If more space is required, use additional copies of NRC Form 366A) 1171 Safety Significance (Cont'd) 12, Action 26 (a)) prior to the release. The second sample was analyzed after the release and determined to be in agreement with the spectrum of the first sample. The results of the analysis showed that the CVCSMT low activity waste was below the TS concentration limit for a liquid effluent release.

There was no Industrial Safety, radiological impact, or nuclear safety issues

associated with this event. The nature of the violation was lirni ted to "failure to analyze the second independent sample prior to initiating the release in accordance with Technical Specifications."

The CVCSMT stores the treated or low activity waste for analysis prior to discharging the waste through a monitored (2Rl8) line to the service water discharge header and then to the circulating water discharge. Channel 2Rl8 continuously monitors liquid radwaste released from Salem Unit 2. If a radiation alarm setpoint is exceeded or a monitor failure occurs, the channel initiates a closure signal to the 2WL51 isolation valve.

The 2Rl8 RM was declared inoperable since May 6, 1995 due to a RM System CPU and Software problem associated with the proper functioning of the overhead annunciator light and alarm. However, the RM was maintained and functional during this period. The RM (2Rl8) was calibrated April 11, 1995 and passed its functional check June. 27,1995. During the release evolution on July 5, 1995 the status of the RM (although declared inoperable) would have isolated the 2WL51 valve as designed upon detection of concentrations in excess of setpoint limits thereby terminating the release in progress. The Control Room would also have received a 2WL51 alarm, acknowledged the alarm and received a printout of the alarm condition.

Corrective Actions Actions to correct the error and preclude future occurrences include the following:

1. The second sample was arialyzed and determined to be in agreement with the first sample on July 5, 1995 at 0842 hours0.00975 days 0.234 hours 0.00139 weeks 3.20381e-4 months .

2. Chemistry Procedure SC.CH-TI .ZZ-0189 (R), "Radiological Effluent Discharge Report Generation and Completion" has be!=n revised to include a "checkoff" for the technician which states, "verify two independent samples have been analyZed, are in agreement, and spectrum attached" to release documents. This revision applies to both liquid and gaseous releases.

NRC FORM 366A (5-921

NRC FORM 366A U. . UCLEAR REGULATORY COMMISSION A VED BY OMB NO. 3150-0104 (5-92) EXPIRES 5131195 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS .

INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE LICENSEE EVENT REPORT (LER) INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, TEXT CONTINUATION WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE 13)

YEAR SEQUENTIAL REVISION SALEM GENERATING STATION, UNIT 2 05000311 NUMBER NUMBER 6 OF 6 95 005 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

Corrective Actions (Cont'd)

3. Operations procedures for liquid and gaseous releases are being revised to require a verification signature. This signature ensures that when a monitor is inoperable, a second independent sample is analyzed. This signature also provides for a second barrier which further precludes the possibility of human error.

4. On July 6, 1995 a Chemistry Department Stand-down was conducted for approximately

2. 5 hours5.787037e-5 days 0.00139 hours 8.267196e-6 weeks 1.9025e-6 months to discuss this event and other less significant events. Technicians provided feedback to supervision as to why they think this event occurred and what Chemistry can do as a department to prevent future events. supervision introduced PARC, (Prioritize, Avoid,- Relaxation, Control) to the technicians and received a cormni tment from them to use this concept . The technicians not present during the stand-down (e.g., vacation, ill, critical activities) were afforded the same opportunity during the Human Error Reduction Training conducted on 7/13 and 7/14/95.

5. On July 7, 1995, a "For Your Information (FYI)" bulletin was issued to Salem station personnel concerrP-ng this event. This FYI contained a brief analysis of the event and a discussion of defense barrier breakdowns. FYI's are a vehicle through which iteins considered important to PSE&G management are communicated to all station employees and facilitate supervisor and employee discussions and involvement, as

. applicable.

6. A review of the Chemistry workload vs. staffing was performed. Chemistry supervision determined that adequate coverage was available.

7. On July 7, 1995 the technician involved was disciplined in accordance with the Positive Discipline Process for inadequate work performance.

8. Chemistry Technicians attended Chemistry specific Human Error Reduction Training similar to the training received by PSE&G management . This training provides the

.technicians with coping mechanisms for handling self-imposed and other job related pressures.

9. Those technicians who missed the Chemistry specific Human Error Reduction Training will discuss the concept of error reduction with their supervisor after they return.

10. Required reading of the LER by all Chemistry Technicians will be conducted upon issuance of the LER.

11.The new chemistry procedure revision will be reviewed with the Chemistry Technicians upon issuance.

NRC FORM 366A (5-92)

ML18101A875

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