ML19325E584

LER 89-034-00:on 891004,discovered That Inservice Station HVAC Exhaust Stack Process Radiation Monitor Had Not Been Verified as Operable,Contrary to Tech Spec 3.3.7.12.Caused by Lack of Training & Inadequate communication.W/891101 Ltr

ML19325E584
Person / Time
Site:	Clinton
Issue date:	11/01/1989
From:	Holtzscher D, Miller D ILLINOIS POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-034, LER-89-34, U-601551, NUDOCS 8911080044
Download: ML19325E584 (6)

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'llLIN019 POWER COMPANV  !

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November 1, 1989 n

P i 10CFR50,73 j L  ;

I Docket No. 50 461

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U.S. Nuclear Regulatory Commissinn l Document Control Desk

• Wshington, D.C. 20555 i

Subject:

Clinton Power Station . Unit 1 .,

Licensee Eventlecort No. 89@i,QQ

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Dear Sir:

Tlease find enclosed 1Acenree Event Report No,89-034 00:

Lack of. Training. Personnel Irror'and Inadecuagg Con.munieggiqng,.) Ray 3 ,

,(n Failure to Verify Precess Radj,gri.on.. Monitor Ooerobility and to Meet [

Iechnical Soecification Recuirements, This report is being submitted in  !

accordance with the requirements of 10CT1tSO.73.  ;

Sincerely yours, 5 ). W D. L. Holtzscher Acting Manager . -

Licensing and Safety TSA/kra  ;

' Enclosure [

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L NRC Region III, Regional Administrator i INFO Records Center  ;

Illinois Department of Nuclear Safety NRC Clinton Licensing Project Manager i

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On October 4, 1989, a Radiation Protection Shift Supervisor (RPSS) u discovered that the in service Station Heating, Ventilatinh and Air Conditioning (HVAC) Exhaust Stack Process Radiation Monitor (PRM),

j ORIX PR001 had not been verified as operable. This resulted in a failure l to meet the Limiting Condition for Operation for Technical Specification l (TS) 3.3.7.12. This TS requires that one Station HVAC Exhaust Stack PRM i be operable at all times. At 0826 hours0.00956 days <br />0.229 hours <br />0.00137 weeks <br />3.14293e-4 months <br />, PRM ORIX PR002 was removed from service and PRM ORIX PR001 was placed in service. The Radiation ,

1 Protection (RP) technician (tech) transferring the monitors did not perform all of the checks required to verify that PRM ORIX PR001 was ,

operable after piccing it in service. Specifically, the RP tech performed a channel check on the monitor but did not verify flow.

Therefore, the PRM was inoperable. This event was caused by lack of training, personnel error and inadequate communications. The RP tech was not fully qualified and the RPSS failed to direct the RP tech to use applicable procedures when placing PRM ORIX FR001 in service. Corrective l actions include reminding appropriate RP personnel of the need to use and l follow procedures, and counselling RP Shift Supervisors on the need to ensure techs are qualified and on the need to review and status activit.ies affecting RP.

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DESCRIPTION OF EVENI I On October 4, 1989, t.he plant was in Mode 1 (POWER OPERATION) and the reactor [RCT) was at eighty five percent power. On the morning of October 4, 1989, Chemistry personnel contacted the Rad!ation Protection ,

(RP) technician assigned as the Area / Process Radiation Monitor (AR/PR) l operator and requested that Radiation Protection personnel remove the in-service Station Heating, Ventilation, and Air Conditioning (HVAC) Exhaust Stack Process Radiation Monitor (PRM) [IL), ORIX PR002, from service and place the redundant monitor [ MON), ORIX PR001, in service. This monitor  ;

transfer is performed weekly to ensure the monitors are used equally and to enable Chemistry personnel to replace the ffiters (FLT) in the  ;

monitors in accordance with Technias,1 Sp9eification Table 4.3.7.12 1. ,

The technician assigned as the AR,'PR operator had rot previeur',y ,

performod a monitor exchange and therefore requastod direut'on frosn the  :

c'ay shif t 'u.diation Protectica Shif t Supetvisor (RPSP.,. The RPSS j explained to the technician the wethodology for removing monitor ,

ORIX PR002 from service ano placing it in "starJbya and the et.hodology.

for placing redundmot monitor ORIX PR001 in service ( normal") . The RTSS directed the technician to note the coepletion of the honLter exchange in i the RP log. The exchange van cogleted at 0826 hours0.00956 days <br />0.229 hours <br />0.00137 weeks <br />3.14293e-4 months <br />. After completing the exchange, the RP techn! clan performt,d s channel [CHA) check on monitor ORIX PR001 by comparing its indication with the last indication of inonitor ORIX PR002. This check verified that monitor ORIX PR001 was in service and was providing accurate data to the Central Control Terminal (CCT) in the RP office.

At 1944 hours0.0225 days <br />0.54 hours <br />0.00321 weeks <br />7.39692e-4 months <br />, during review of completed surveillance procedure 9911.24, "AR/PR Shiftly/ Daily Surve111ances", the second shift RPSS noted that not all checks required to verify operability of monitor ORIX PR001 were ,

doc'iment ed.  :

The RPSS di'tected the second shift RP technician assigned as the AR/PR ,

operator to perform surveillance 9911.24 to verify that monitor ORIX. I PR001 was operable. In accordance with surveillance 9911.24, the RP technician performed a channel check and a sample flow indicator [FI) check. Surveillance 9911.24 was completed at 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> with i satisfactory results. (A communications check, which is required to be ,

performed once each shift, was documented as having been completed at '

0741 hours0.00858 days <br />0.206 hours <br />0.00123 weeks <br />2.819505e-4 months <br /> and 1555 hours0.018 days <br />0.432 hours <br />0.00257 weeks <br />5.916775e-4 months <br />.) 6 Since the checks to verify the operability of monitor ORIX PR001 were not performed within one hour of placing monitor ORIX PR001 in service, the Limiting Condition for Operation (LCO) for Technical Specification 3.3.7.12 was not met. Technical Specification 3.3.7.12 requires that one station HVAC exhaust PRM be operable at all times. Operability of ORIX.

PR001 was not verified until 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> on October 4, 1989, 1

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t Technical Specification 3.3.7.12 permits a Station INAC Exhaust Stack PRM to be placed in an inoperable status for up to one hour for the purpose .

of performing sutveillances. Monitor ORIX PR001 was placed in service at i 0826 hours0.00956 days <br />0.229 hours <br />0.00137 weeks <br />3.14293e-4 months <br />, therefore the LCO for Technical Specification 3.3.7.12 was not met from 0926 hours0.0107 days <br />0.257 hours <br />0.00153 weeks <br />3.52343e-4 months <br /> until 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> on October 4, 1989.

Ne automatic or manually initiated safety system responses were necersary to place the plant in a safe and stable condition. No other eyvipent o; conponents were inoperabic at the start of this event such that their ,

inoperable condition contributed to this event. l 2 disl Ol' Eff.EI.

The cause of the event is attmibuted to inck of training, personnel artor and inadequatc comtaunications, g Tha RP technician assigned as the AR/PR operator was not fully qualified

, I. for that posit 3on becauce he had not completed all of the required training. He was horever, considered to have sufficient experience and to have demonstrated a level of proficiency sufficient to perform AR/PR i

operator activit.as under the direct supervision of fully qualified personnel.

i The RPSS failed to direct the RP technician to use the procedures governing the operation and testing of the AR/PR monitors when removing monitor ORIX PR002 from service and placing monitor ORIX PR001 in service. Radiation Protection procedure 7410.75, ' Operation of Digital AR/PR Monitors" provides instructions for removing monitors from service, for starting monitors, and for returning monitors to serrice.

Surveillance procedure 9911.24 provides instructions for performing the checks required to verify monitor operability. Neither of these procedures was utilized when transferring the Station INAC Exhaust Stack PRMs and verifying their operability.

Contributing to the failure to meet the LCO for Technical Specification 3.3.7.12 was the lack of involvement of the RPSS in the monitor transfer process. The RPSS was aware that the monitor transfer was to occur because the evolution had been discussed at the Operations shift I

turnover. However, the RPSS did not discuss the monitor transfer with RP l

personnel at the RP shift turnover. The RPSS did not follow up to ensure the monitor transfer had been completed satisfactorily.

In addition to performing AR/PR operator duties, the RP technician was acting as the on duty RP office technician performing routine RP office work. The RP technician was required to perform the additional duties because of the high volume of routine RP office work required to be performed in the first few hours of each shif t. Performing the duties of l

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both positions adversely affected the RP technician's performance of his AR/PR operator duties.

Procedure 7410.75 was reviewed following the event and it was determined that even if the applicable proceditres had been used when removing monitor OR1X PR002 from service and placing monitor ORIX PR001 in '

service, all of the checks required to verify operability may not have been performed. Procedure 7410.75 did not address the requirement to ,

perform surveillance 9911.24 when placing AR/PR monitors in service.

Procedure 7410.75 did not require that the Operatiene Shif t Supervisy r t e notified of monitor operability onu. the AR/PR monitors reyttired te acet a

Technical Specifications were placed in service. Operationa petronnel '

were natified that n.onitor ORIX PR001 was placed in service and that. the ,

monitor was op3 rating properly. Operations personnel believed that when -

RP pers onnel stated tt'at monitor ORIX PR001 was operating properly , i checks required to meet the requirements of Technical Specification 3.3.7.12 had been completed with aatisfactory rvsults.

G,RRECTIVE ACTIQNf3 Radiation Protection Shift Supervisors have been counselled on the need I to ensure that RP technicians are fully qualified for the positions to ,

which they are assigned. The Radiation Protection Shift Supervisors were also ceunselled on the need to review the Daily Activity Schedule for upcoming activities which involve or affect Radiation Protection, and on the need to discuss the status of these activities at the RP shift turnover meetings. ,

A night order was issued to appropriate Radiation Protection personnel regarding: the need to use procedures, particularly when placing monitors in service from a " standby" condition; the checks required to be performed in accordance with surveillance 9911.24; and the requirement to '

notify Operations personnel when changing the status of monitors meeting Technical Specification requirements.

A night order was issued reminding appropriate Radiation Protection personnel that whea assigned to a position it is their responsibility to ensure that they meet the requirements of that position prior to assuming any additional duties or positions. This ensures that requirements are met, while at the same time providing for flexibility and reassignment of I personnel.

Proceduren 7410.75 and 9911.24 have been revised to include the steps required to be completed to verify AR/PR monitor operability, and to include a step requiring that operations personnel be notified when a monitor is placed in service and when surveillance procedure 9911.24 has

been satisfactorily completed.

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i ANALYSIS OF EVENT This event is reportable in accordance with the provisions of  ;

10CFR50.73(a)(2)(1)(B) due to operation prohibited by Technical I i

Specifications. The 140 for Technical Specification 3.3.7.12 was not met from 0926 hours0.0107 days <br />0.257 hours <br />0.00153 weeks <br />3.52343e-4 months <br /> until 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> on October 4, 1989.

Aasessment of the nuclear safety consequences and inp11 cations of this i event indicated that this event was not safety significant for existing ,

or other p?. ant conditions. Cumpletion of survet11ance 9911.24 with satisfactory results indies.tes thet.sonitor ORIX.P3001 ess a.ccurately monitoring effluent through the Common HVAC Stack, e&D.LT12ML 1NNP. MAT 10N l

',, liu 88 020 00 discusse(. ttn failure to ensure that a liquid efaturnt .

l roonitor vr.e placed 1,1 an operat,le status prioY to bi-ing dsclared 1 operable. The cause cf this event wars vague coinanications bacween  ;

Operations and Rad 16 tion Protection ;eis.onnel regarding whether the annitor was in "normala or " standby'.

For further information regarding this event, contact D. W. Miller, Director Plant Radiation Protection, at (217) 935 8881, extension 3313.

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