ML18005A581

LER 88-020-00:on 880806,wide Range Gas Monitor Inoperable Due to Loss of Sample Flow & Compensatory Actions Not Taken. Caused by Personnel Error.Procedure Revised for Addl Checks on Monitors & Personnel Received Addl training.W/880906 Ltr

ML18005A581
Person / Time
Site:	Harris
Issue date:	09/06/1988
From:	Schwabenbauer, Watson R CAROLINA POWER & LIGHT CO.
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
HO-880180-(O), LER-88-020, LER-88-20, NUDOCS 8809140333
Download: ML18005A581 (6)

Text

Qf ACCESS10N NBR:8809140333 DOC.DATE: 88/09/06 NOTARIZED: NO DOCKET FACIL:50-400 Shearon Harris Nuclear Power Plant, Unit 1, Carolina 05000400 AUTH. NAME AUTHOR AFFILIATION SCHWABENBAUER Carolina Power & Light Co.

WATSON,R.A. Carolina Power & Light Co.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

.LER 88-020-00:on 880806,wide range gas monitor inoperable due to loss of sample flow & compensatory actions not taken.

W/8 ltr.

DISTRIBUTION CODE'E22D COPIES RECEIVED'LTR ENCL TITLE: 50.73 Licensee Event Report (LER), Incident Rpt, etc.

L SIZE NOTES:Application for permit renewal filed. 05000400 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-1 LA 1 1 PD2-1 PD 1 1 BUCKLEY,B 1 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DSP/NAS -1 1 AEOD/DSP/ROAB 2 2 AEOD/DSP/TPAB 1 1 ARM/DCTS/DAB 1 1 DEDRO 1 1 NRR/DEST/ADS 7E 1 0 NRR/DEST/CEB 8H 1 1 NRR/DEST/ESB 8D 1 1 NRR/DEST/ICSB .7 NRR/DEST/MEB

~1 1 1 9H 1 NRR/DEST/MTB 9H 1 1 NRR/DEST/PSB 8D 1 1 NRR/DEST/RSB 8E 1 1 NRR/DEST/SGB 8D 1 1 NRR/DLPQ/HFB 10 NRR/DLPQ/QAB 10 1 1 NRR/DOEA/EAB NRR/DREP/RPB 10 ll 1 1

2 1

1 2

NRR/DREP/RAB RR715RXS/QIB 10 9A 1

1 1

1 NUDOCS-ABSTRACT 1 1 G F-I=L"E~ 02 1 1 RES TELFORDPJ 1 1 RES/DSIR DEPY 1 1 RES/DSIR/EIB 1 1 RGN2 FILE 01 1 1 EXTERNAL: EG&G WILLIAMSPS 4 4 FORD BLDG HOYPA 1 1 H ST LOBBY WARD 1 1- LPDR 1 1 NRC PDR 1 1 NSIC HARRISPJ 1 1 NSIC MAYSPG 1 1 TOTAL NUMBER OF COPIES REQUIRED: LTTR 46 ENCL 45

NAC Form 366 U.S. NUCLEAR REQULATORY COMMISSION (883)

APPROVED OMB NO. 3160410l EXPIAESl 8/31/88 LICENSEE EVENT REPORT HLER)

FACILITY NAME (I) DOCKET NUMBER (2) PA E 3l SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 0 5 0 0 0 4 0 0 1 OFO 4

'"WIDE RANGE GAS MONITOR INOPERABLE DUE TO LOSS OF SAMPLE FLOW AND COMPENSATORY ACTIONS NOT TAKEN DUE TO PERSONNEL ERROR.

EVENT DATE (5) LFR NUMBER I6) REPORT DATE (7) OTHER FACILITIES INVOLVED (BI

'cl sEQUENT/AL .mm REvrsrQN OAY YEAR FACILITYNAMES DOCKET NUMBERIS)

MONTH OAY YEAR YEAR NVM8EA k?A NVMSEA MONTH 0 5 0 0 0 0 8 0 6 8 8 8 8 0 2 0 0 0 0 9 0688 THIS REPORT IS SUBMITTED PURSUANT T 0 THE REQUIREMENTS OF 10 CFR ((: (Check onr or more Of the folfovflnPI (11) 0 5 0 0 0 OPERATINQ MODE (8) 73.7((8) 5 20A02(bl 20A05(cl 60.73(s I (2)(lv)

POWER 20A05( ~ ) (I IIII 60.38(cl(1) 60.73(sl(2)(v) 73.71(c)

LEYEL 0 0 0 20A05( ~ ) (1)(EI 50.38 Ic) (2) 60.73(sl(2) (vill OTHER (Specify In Ahrrrrcr (2)(vill)(B) hrlovrend /n Text, IIIICForm 20A05( ~ l(1 I(IIl) 50.73( ~ I (2) I I) 50.73( ~ I(2)(vill)(A) 3BBAI 20A05(s)(1)(lvl 60.73( ~ ) I 2)(81 60.73( ~ )

20AOS(sl(1) (vl 50.73(sl(2) (III) 60.73( ~ )(2)(xl LICENSEE CONTACT FOR THIS L'ER (12)

NAME TELEPHONE NUMBER AREA CODE R. SCHWABENBAUER - REGULATORY COMPLIANCE TECHNICIAN me COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPOAT (13)

MANUFAC. EPORTABLE MANVFAC. EPOATABLE CAUSE SYSTEM COMPONENT TO NPRDS CAUSE SYSTEM COMPONENT TURER TUAER TO NPADS (NI(IRR SUPPLEMENTAL REPORT EXPECTED (Ill EXPECTED MONTH OAY YEAR SUBMISSION DATE (16)

YES Ilfyer, comp/ere EXPECTED $ (IBMISSIOII DATE/ NO ABsTRAGT /Llmlr to /cop rprcer, I r., epproxlmmrly /lftrrn rlnple.specs typrvrrfttrn /lnerl (18) 8809140333 88090b PDR ADOCI(s 05000400 ABSTRACT: 8 PNU The plant was in Mode 5, Cold Shutdown, at 0 percent reactor power on August 6, 1988.

Technical Specifications 3.3.3.11 requires the plant vent stack effluent be continuously monitored for noble gases and continuously sampled for particulates and iodines. The lant vent stack Wide Range Gas Monitor (WRGM) which does this is powered by the lA-SA afety Bus.

Operations personnel were in the process of performing Operations Surveillance Test (OST)-

1823, lA-SA Emergency Diesel Generator (EDGJ 18 Month Operability Test. Part of the test calls for the dropping of the. 1A-SA Safety Bus to simulate a loss-of-power to ensure the EDG starts and assumes 1A-SA safety train power loads.

At 0346 hours0.004 days <br />0.0961 hours <br />5.720899e-4 weeks <br />1.31653e-4 months <br /> operations personnel dropped the 1A-SA Safety Bus. The 1A-SA EDG started as required and restored power to the 1A-SA safety-related equipment.

Power was restored to the WRGM; ho~ever, the sample pump, which draws the air through the WRGM, does not automatically restart once power is lost. The sample pump has to be manually restarted from the control console and personnel at the consoles did not recognize that the sample pump was not running.

At 1843 hours0.0213 days <br />0.512 hours <br />0.00305 weeks <br />7.012615e-4 months <br />, approximately 15 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br /> later, personnel discovered the sample pump was not running as required and restarted it to restore sample flow to the WRGM.

The cause of the event was personnel error as lost to the WRGM.

it was not'noticed that sample flow had been Corrective actions include: procedure revision for additional checks on monitors and additional training for personnel'here were no safety consequences as a result of this event and is being reported in accordance with 10CFR50.73(a)(2)(i)(B) as a violation of Technical Specifications.

NAC Form 386 M l\'0 ~

NRC FOIm 344A U.S. NUCLEAR REOULATORY COMMISSION (983)

LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVEO OMB NO. 3)9)-0104 EXPIRES: 8/31/88 FACILITY NAME (I) OOCKET NUMBER (2) LER NUMBER (4) PACE (3)

SEOVSNTIAL REVISION YEAR gw NUMBER NVM ER SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 o s o o o 40 0 88 0 20 0 0 0 2 QF0 4 TEXT /// II>>SF <<>>c>>>> /R)v/sRL vss sea//I/sns////IC %%dmI %$ 4'4/ (17)

DESCRIPTION:

The plant was in Mode 5., Cold Shutdown, at 0 percent reactor power on August 6, 1988. Plant Technical Specifications (TS) 3.3.3.11 and table 3.3.13 require the plant vent stack (EIIS:VL) effluent be continuously monitored for noble gases and continuously sampled for particulates and iodines. The minimum required channels for each function is one. With less than the minimum required channels operable, a noble gas grab sample must be taken every 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> and particulates and iodines must be sampled continuously through the use of a portable monitor. There are two separate monitors on the plant vent stack, a particulate iodine and gas monitor (PIG) and a wide range gas monitor (WRGM) RM-21AV-3509-1SA (EIIS:IL)-. These monitors are powered by the 1A-SA Safety Bus (EIIS:EA).

Operations personnel were in the process of performing Operations Surveillance Test (OST)-1823, 1A-SA Emergency Diesel Generator (EDG)(EIIS:EK) 18 Month Operability Test Modes 5 and 6. A portion of OST-1823 requires the dropping of the 1A-SA Safety Bus, which simulates a loss of power, to verify the lA-SA EDG starts and assumes lA-SA safety train loads.

At 0346 hours0.004 days <br />0.0961 hours <br />5.720899e-4 weeks <br />1.31653e-4 months <br /> power was dropped to the 1A-SA Safety Bus causing a momentary loss of power to the A train safety related equipment. The 1A-SA EDG started as required and restored power to the A train safety related equipment.

Power was restored to the WRGM; however, the sample pump does not restart automatically and needs to be manually started by personnel. .At thos point the WRGM was without sample flow. This loss of sample flow conditio() was not noticed by the Radiation Control (RC) Technician at the Radiation Monitor (RM)-11 console. Also, the loss sample flow visual indication on the RM-ll or the RM-23 in the Main Control Room (MCR) was not noticed by operations personnel.

a At 1843 hours0.0213 days <br />0.512 hours <br />0.00305 weeks <br />7.012615e-4 months <br /> the night shift RC Technician at the RM-11 console n( ticed that the plant vent stack WRGM was in an operate failure condition and called up the status screen for that monitor. The screen indicated that the monitor was in a loss of sample flow condition. The technician then called the MCR to see if there was any testing or work being performed on this monitor. The MCR personnel indicated no work or testing was being performed so the RC Technician then started the sample pump from the RM-11 console in the Radiation Work Permit (RWP) office. The technician then checked the alarm history for that monitor and notified the MCR the sample pump had been off for the previous 15 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br />.

NRC FORM 344A R U.S.OPO:1888 0-824 538/455 (983)

NRC Form 3ddA U.S, NUCLEAR REGULATORY COMMISSION (983)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMS NO. 3)50&)04 EXPIRES; 8/31/88 FACILITY NAME (1) OOCKET NUMSER l21 LER NUMBER (5) PAGE (31 YEAR y'~o SEOUENZIAL C(rrI REVISION

'~G NUMSE4>>rIII NUM E4 SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 0 5 0 0 0 4 0 0 88 020 00 03o" 0 TEXT ///more u>>ce /I reqrr/rfr/, Irw /R/o'o>>/ HRC Fofm 38((E's/ (17)

CAUSE:

The dropping of the 1A-SA Safety Bus caused the WRGM to lose sample flow.

When the lA-SA EDG started and assumed safety train loads power was restored to the plant vent stack WRGM. The monitor sensed a loss of sample flow due to the sample pump not starting and generated a loss of sample flow alarm. This alarm message was sent to the RM-11 computers that are primary and secondary to that monitor.

Once an RM-11 computer receives an alarm message it does several things with that message. The RM-11 computer sends that message to the other three RM-11 computers. Then each of the four RM-11 computers forward the message to their respective printers and terminals. Each terminal receives the message and generates both audible and visual alarms. When the 1A-SA Safety Bus was dropped each RM-ll terminal and printer received 18 alarm messages in approximately one minute. With this many alarms coming in at one time, associating the audible alarm with any particular monitor channel problem is impossible. Therefore, when many alarms are received, the" visual message is the key to verifying which monitors are in alarm.

When a visual alarm message is received at an RM-ll terminal it causes the block representing that channel on the grid screen to change colors and start flashing. The grid block will continue to flash until the alarm for that channel is acknowledged on each RM-ll. A loss of sample flow alarm would have caused the low range gas channel to change from green to dark blue. Even if the alarm had been acknowledged the grid block would have remained dark blue until sample flow had been restored. However, the- personnel who acknowledged the alarms at the RM-lls did not recognize what actions were needed if the WRGM did not clear (i.e., the color didn't change back to green).

Neither the control room operators nor the RC Technicians manning the RWP office RM-ll terminal between 0346 hours0.004 days <br />0.0961 hours <br />5.720899e-4 weeks <br />1.31653e-4 months <br /> and 1843 hours0.0213 days <br />0.512 hours <br />0.00305 weeks <br />7.012615e-4 months <br /> noticed any off-normal conditions for the plant -ent stack WRGM. The cause of his L)cc( rrence was personnel error in that neither the RC Technicians nor the control room personnel noticed the loss ofr sample flow alarm.

It must be noted that there are other conditions that probably contributed to this loss of sample flow condition being missed. The flow indicator light on the RM-23 display for the plant vent stack was burned out. This could have led to some confusion as to whether or not the WRGM had sample flow. The radiation monitoring system has been having loop communication problems, which can mask other alarms for short periods of time.

NRC FORM 3EEA <<U.S GPO.(088-0.824 538/455 (8831

NRC Form 3SSA U.S. NUCLEAR REGULATORY COMMISSION (94)3)

LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVED OMS NO. 3/50&104 EXPIRES: S/31/8$

FACILI'TY NAME 11) DOCKET NUMSER C)l LER NUMSER IS) ~ AGE )3)

SEQUENTIAL >rrp 4EVISK)N SHEARON HARRIS NUCLEAR POWER PLANT YEAR ~~)p:

4)'o NUMS 4 4:Pro N U Mo 4 4 UNIT 1 TEXT /// moro Epoco /4 /ol/rkorL opo //O/roo/ HRC /rorrrr 3/E)4 3/ ) IT) os << o 40 0 SS 02000 0 4 QF 0 4 CAUSE (continued)

There is no printer at the RM-11 terminal in the RWP office which would provide a listing of alarms on the system. Consequently, if the radiation monitoring system RC Technician is out of the office for other duties, information is not readily available to him/her as to what alarms occurred during that time if they were acknowledged by other personnel in the office.

ANALYSIS:

There were no safety consequences as a result of this event.

The plant vent stack was an unmonitored release path for approximately 15 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br />. Even though the PIG was inoperable, due to a problem with the iodine detector, it was still capable of monitoring noble gases. The alarm history printouts for August 6, 1988 indicate the plant 'vent stack PIG monitor did not go into alert or high alarm at any time. In addition, routine air samples taken during this time frame did not indicate any airborne contamination problems in the plant.

The event is being reported in accordance with 10CFR50.73(a)(2)(i)(B) as a violation of Technical Specifications 3.3-13 Actions 47 and 49.

There have been no previous similar events reported.

CORRECTIVE ACTIONS/ACTION TO PREVENT RECURRENCE:

1. Health Physics Procedure (HPP) 501, Routine Surveillance of Radiation Monitoring System, will be revised so that the trend checks of Technical Specification radiation monitors will be performed once a shift, rather than daily as currently required. A form on which to document this trend check S)iIl be added to the procedure.

2. Appropriate personnel will receive additional 'training on the alarm functions and displays of both the RM-23 and RM-lf terminals.

NRC FORM ESSA *V.S.GPD;ISSB 0 524 535/455 (SS3)

I C~4 Carolina Power & Light Company h

HARRIS NUCLEAR PROJECT P.O. Box 165 New Hill, NC 27562 SEP 0 61988 File Number: SHF/10-13510C Letter Number'HO-880180 (0)

U.S. Nuclear Regulatory Commission ATTN: NRC Document Control Desk Washington, DC 20555 SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 DOCKET NO. 50-400 LICENSE NO. NPF-63 LICENSEE EVENT REPORT 88-020-00 Gentlemen.'n accordance with Title 10 to the Code of Federal Regulations, the enclosed Licensee Event Report is submitted. This re'port fulfills the requirement for a written report within thirty (30) days of a reportable occurrence and is in accordance with the format set forth in NUREG-1022, 'September 1983.

Very truly yours, R. A. Watson Vice President Harris Nuclear Project RJS:dj Enclosure cc'Dr. J. Nelson Grace (NRC RII)

Mr. B. Buckley (NRR)

Mr. W. H. Bradford (NRC-SHNPP)

MEM/LER-88-020 .(OSI