ML17305A276

LER 89-008-01:on 890509,calculational Error Identified in Surveillance Test That Would Have Resulted in Boron Diluted Alarm Channel 2 Being Inoperable.Caused by Personnel Error. Technicians Counseled & Test Procedure revised.W/891006 Ltr

ML17305A276
Person / Time
Site:	Palo Verde
Issue date:	10/06/1989
From:	James M. Levine, Shriver T ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
192-00535-JML-T, 192-535-JML-T, LER-89-008-01, LER-89-8-1, NUDOCS 8910170023
Download: ML17305A276 (16)

Text

AC CE1ERATED Dl ST'RTBU'n ON DE MONSTERION SYSTEM REGULATORY INFORMATION DISTRIBUTION 'SYSTEM (RIDS)

ACCESSION NBR:8910170023 DOC.DATE: 89/10/06 NOTARIZED: NO DOCKET FACIL:STN-50-529 Palo Verde Nuclear Station, Unit 2, Arizona Publi 05000529 AUTH. NAME AUTHOR AFFILIATION SHRIVER,T.D. Arizona Public Service Co. (formerly Arizona Nuclear Power LEVINE,J.M. Arizona Public Service Co. (formerly Arizona Nuclear Power RECIP.NAME RECIPIENT AFFILIATION SUMECT: LER 89-008-01,:on 890509,improper performance of surveillance test for startup Channel 2.

ltr.

W/8 DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL '

SIZE:

TITLE: 50.73/50.9 Licensee Event Report (LER), Inciden Rpt, etc.

NOTES:Standardized plant. 05000529 j RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD5 LA 1 1 PD5 PD 1 1 CHAN,T 1 1 DAVIS,M. 1 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2.

DEDRO 1 1 NRR/DEST/ESB 8D 1 1 NRR/DEST/ICSB 7 1 1 NRR/DEST/MEB 9H 1 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 1 1 NRR/DLPQ/PEB 10 1 1

.NRR/DOEA/EAB 11 1 1 RRy'4) RPB 10 2 2 NUDOCS-ABSTRACT 1 1 ~G I F LE 01 1

1 1

1 RES/DSIR/EIB 1 1 RGN5 EXTERNAL: EGGG WILLIAMS,S 4 4 L ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC MAYS,G 1 1 NSIC MURPHY,G.A 1 1 NUDOCS FULL TXT 1 1 NOTES 1 1 NOTE 'IO ALL RZDS" RECZPZERIS PIZASE HELP US 'XO REDUCE %ASTE! CGMZAC1'HE DOCUMEFI'XNZROL DESK, RXH Pl-37 (EXT. 20079) XO ELIKBRXB KXK NAME FKH DIBTBZBUZICH LISTS FOR DOCUMEHZS VXJ MHiT NEEDf FULL TEXT CONVERSION REQUIRED 40' TOTAL NUMBER OF COPIES REQUIRED: LTTR 40 ENCL

0 Arizona Public Service Company PALO VERDE NUCLEAR GENERATING STATION P.O., BOX 52034 ~ PHOENIX. ARIZONA 85072-2034 192-00535-JML/TDS/JEH'ctober 6, 1989 U. S. Nuclear Regulatory Commission NRC Document Control Desk Washington, .D.C. 20555

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Unit 2 Docket No. STN 50-529 (License NPF-51)

Licensee Event Report 89-008-01 File: 89-020-404 Attached please find Supplement Number 1 to Licensee Event Report (LER) No.

,89-008-00 prepared and; submitted pursuant to the requirements of IOCFR 50.73.

In accordance with 10CFR 50'.73(d), we are herewith forwarding a copy of this report to the Regional Administrator of'he Region. V Office.

If you have any questions, please contact T. D. Shriver, Compliance Hanager at

.(602) 393-2521.

Very truly yours, Vice President Nuclear Production JGH/TDS/JEH/kj Attachment cc: W. F. Conway (all w/a),

E. E. Van Brunt, Jr.

J. B. Hartin T,. J. Polich H. J. Davis A. C. Gehr INPO Records Center

IS Ik i'

NRC FORM 368A V.S. NUCLEAR REGULATORY COMMISSION

)669) APPROVED OMB NO. 31504)04 EXPIRES: S)30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COI.LECTION RECUEST: 500 tIRS. FORWARD CQhhMENTS REGARDING BURDEN FSTILIATE TO THE RECORDS TEXT CONTINUATION AND REPORTS SIANAGEMENT BRANCH IP-530). V.S. NUCLEAR REGULATORY COMMISSION. 'VASHINGTON. DC 0555, AND TO THE PAPERWORK REDUCTION PROJECT 13150410S). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME I11 DOCKET NUMBER 12) LER NUMBER 18) PAGE ISI VEAA ig( SEOVENTIAI REVISION NVMREA NVMSEA Palo Verde Unit 2 o s o o o 52 9 8]9 00 8-0 1 02 0 6 TEXT illmont S>>stis rtOV~. ost sdorriorIsr lVIICform 3664'sl OT)

DESCRIPTION OF WHAT OCCURRED:

A. Initial Conditions:

At approximately 0840 HST on Hay 9, 1989, Palo Verde Unit 2 was in Mode 5 (COLD SHUTDOWN) with Reactor Coolant System (RCS)(AB) temperature at approximately 130 degrees Fahrenheit (F) and pressurizer (PlR)(AB) pressure at approximately 133 psia, B. Reportable Event Description (Including Dates and Approximate Times of Major Occurrences):

Event Classification: Any operation or condition prohibited by the plant's Technical Specifications.

At approximately 2030 MST on May 8, 1989, an Instrument and Cont} ol

( I&C) Technician (utility, non-licensed) successfully completed Surveillance Test 36ST-9SE05, "Boron Dilution Functional Alarm Check," based on a calculational error which resulted in the Surveillance Test meeting the acceptance criteria. Based on the successful completion of 36ST-9SE05, Startup Channel 2 (JC) was returned to service at approximately 2154 MST on May 8, 1989 and the associated Technical Specification ACTION statement 3. 1.2.7 b. 1 was exited. At approximately 0745 HST on May 9, 1989, an I&C Work Group Supervisor (WGS)(utility, non-licensed) identified the calculational error in the Surveillance Test. Correct performance of the calculation would have resulted in Boron Dilution Alarm Channel 2 not meeting the acceptance criteria.

Prior to the event at approximately 1600 MST on May 8, 1989, testing was in progress on Startup Channel 1 when an increase in indication was noticed on Startup Channel 2. A Reactor Operator (RO)(utility, licensed) went to the cabinets (CAB)(JC) where the Instrument and Control ( I&C) Technician (utility, non-licensed) was performing 36MT-9SE07, RExcore Startup Channel Calibration," on Startup Channel 1. The RO verified with the I&C Technician that testing was being performed on Startup Channel 1 only. The test lineup was verified to be correct; however, a test lead connection to a High Voltage probe was found to be loose. When the test lead connection was placed in front of a Startup Channel 2 sealer jack and the High Voltage was energized for the test, an Electro-'Magnetic Field was induced into Startup Channel 2 drawer causing an increase in indication on Startup Channel 2. When the High Voltage was turned off, the indication returned to the normal level.

A telephone conversation was held between the Operations Manager NR C Form 368A I 649)

0 NRC FORM 366A U.S. NUCLEAR REGULATORY COIAMISSION APPROVED OMB NO.31500104 16691 EXPIRES: 4I30t92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT tLER) INFORMATION COLLECTION REQUESTI 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS LIANAGEMENTBRANCH IP.5301, U.S. NUCI.EAR REGULATORY COMMISSION, WASHINGTON, OC 20555. AND TO THE PAPERWORK REDUCTION PROJECT 1315001041. OFFICE OF MANAGEMENTANO BUDGET,WASHINGTON.OC 20503.

FACILITY NAME 11) DOCKET NUMBER 121 LER NUMBER 161 ~ AGE I3)

VEAR SEQUENTIAL REVISION NUMIIEII +".4 NUMOER Palo Verde Uni t 2 o s ]o o ]o 5 2 9 8 9 00 8 0 1 03 o" 0 6 TEXT It/more 4oeoe IB reevrtert, oeo edChcionel ittIC Form JtISAS I IITI (utility, non-licensed), the System Engineer (SE)(utility, non-licensed), the ILC Technician and the Work Group Supervisor (WGS)(utility, non-licensed). During the conversation the System Engineer agreed that the loose connection and the location of the test lead was the most likely cause of the increased indication on Startup Channel 2. However, Surveillance Test 36ST-9SE05, "Boron Dilution Functional Alarm Test," was performed to ensure no anomalies existed in Startup Channel 2.

At approximately 1712 HST on Hay 8, 1989, Startup Channel 2 was declared inoperable to perform 36ST-9SE05. Chemistry personnel were instructed to take two independent boron samples in accordance with Technical Specification 3. 1.2.7 ACTION b. 1 since 'both channels were now declared inoperable. The surveillance test was completed, and at approximately 2154 HST on Hay 8, 1989, Startup Channel 2 was declared operable. Technical Spe'cification 3. 1.2.7 ACTION b. 1 was then. exited. However, since Startup Channel 1 was still inoperable ACTION a. 1 was still applicable.

At approximately 0745 HST on May 9, 1989, while performing the WGS review of 36ST-9SE05 for Boron Dilution Alarm Channel 2, the WGS identified a calculat'ional error in the performance of the surveillance test that, if performed correctly, would have resulted in Startup Channel 2 not meeting acceptance criteria. The error was made in the following step:

8.2:4. 10 Subtract Test Low display (step 8.2.4.9) from the Setpoint display (step 8.2.4.3) and record on data sheet (Block 1). This should equal the Delta Setpoint plus 0.10 VDC.

The technician performed the subtraction correctly and believed he should add 0. 10 VDC. When the technician added the 0. 10 VDC, the result met the acceptance criteria and the technician believed he performed the test satisfactorily. However, the last sentence of the step was meant to be a clarifier and not an action of the step.

The Shift Supervisor was notified and Startup Channel 2 was declared inoperable at approximately 0840 HST on Hay 9, 1989. At approximately 0845 HST on Hay 9, 1989, two independent boron samples were taken to comply with Technical Specification 3. 1.2.7 ACTION b. 1 and 36ST-9SE05 was reperformed satisfactorily. At approximately 1132 HST on May 9, 1989, Startup Channel 2 was declared 'operable.

No work was performed on Startup Channel 2 during this time frame.

36ST-9SE05 is a monthly surveillance test and was satisfactorily NRC Farm 366A 164IBI

0 NRC FORM366A U.S. NUCLEAR REGULATORY COIAMISSION (64)9) APPROVED OMB NO. 31504))04 E XP IR E 3: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT {LER) INFORMATION COLLECTION REOUESTP 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPOR'TS MANAGEMENT BRANCH (P-530), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31504))041. OFFICE OF MANAGEMENTAND BUDGET. WASHINGTON,OC 20503.

FACILITYNAME (ll DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR jQP, SEOUENSIAL'UMSER @'p REVISION NUMSER Palo Verde Unit 2 o s o o o 52 989, 0 0 8 0 1 04oFO 6 TEXT /// moro sosco is rsr/Ir/rsd, oso sddi rroos//VRC Form 3664 4/ (12) performed on May 12, 1989. All appropriate ACTION's were performed during the. period that Startup Channel 2 was declared inoperable.

However, from approximately 2154 HST on Hay 8, 1989 to approximately 0840 HST on Hay 9, 1989, Technical Specification

3. 1.2.7 ACTION b. 1 was not performed as required.

An independent review of recent performances of 36ST-9SE05 was performed. At approximately 0830 MST on June 7, 1989, a Compliance Engineer (utility, non-licensed) discovered that the same I&C Technician made this calculational error while performing Surveillance Test 36ST-9SE05 on April 17, 1989. Th'e II)C Technician made a calculational error in the performance of the surveillance test that, if performed correctly, would have resulted in Startup Channels 1 and 2 not meeting the acceptance criteria. Since the error was not identified at the time, the appropriate ACTION's of Technical Specification 3. 1.2.7 were not performed from approximately 1045 MST on April 17, 1989, to approximately 0840 HST on Hay 9, 1989.

The review of recent performance of 36ST-9SE05 revealed that the surveillance test was satisfactorily performed on March 20, 1989 and on May 9, 1989, A review of work orders during this time frame showed that no work had been performed on. the Startup Channels during this time.

C. Status of structures, systems, or components that were inoperable at the start of the event that contributed to the event:

No structures, systems, or components 'were inoperable at the start of the event that contributed to .the event other than described in I.B above.

D. Cause of each component or system failure, if known:

Not applicable -. there were no component or system failures..

E. Failure mode, mechanism, and effect of each failed component, if known:

Not applicable - there were no fai.led components.

For failures of components with multiple functions, list of systems or secondary functions that were also affected:

Not applicable - there were no failed components.

NRC Form 366A (64)9)

ll l NRC FORM 366A U.S. NUCLEAR REGULATORY COIAMISSION (66)9) APPROVEO 0MB NO.31504104 EXPIRES: 4/30192 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE'EVENT REPORT (LER) INFORMATION COLLECTION REQUESTs 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH IP-530), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31504)104), OFFICE OF MANAGEMENTAND BUDGET. WASHINGTON, DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER IS) PAGE (3) pre r?!a SEOVSNTIAL NVMSSR I?i ASVISlON NUMSS rs Palo Verde Unit 2 o s o o o 52 989 0 0 8 01 05 oF 06 TEXT illmoro sasss is rsauirsd, uso addi rioosl FVRC Farm 3664'sl (17)

G. For failures that rendered a train of a safety system inoperable, estimated time elapsed from the discovery of the failure until the train was returned to service:

Not applicable - no failures were involved.

H. Method of discovery of each component or system failure or procedural error:

The error in the performance of the Surveillance Test was discovered by the I&C Work Group Supervi'sor at approximately 0745 MST on Hay 9, 1989, during the review of the Surveillance Test.

I. Cause of Event:

The cause of the event was a personnel error on the part of the I&C Technician (utility, non-licensed) performing the test in that he perceived the 'clarifying sentence of the step to be part of the required calculation. The I&C Technician incorrectly performed the required calculation. Additionally the I&C Technicians performing the independent review did not identify the calculational error.

There were no operator errors that contributed to the event. There were no unusual characteristics of the work location that

-contributed to the event. The error was contrary to an approved procedure and there were no errors in the procedure. However, the procedure misled the Technician as discussed above in section I.B.

The I&C Supervisor believed the Surveillance Test to be adequate however, an Instruction Change Request was submitted to make the procedure more explicit.

J. Safety System Response:.

No manual or automatic safety system responses occurred and none were required.

K. Failed Component Information:

Not applicable - no failed components were involved.

II. ASSESSMENT OF THE SAFETY.CONSEQUENCES AND IMPLICATIONS OF THIS EVENT:

There are no safety consequences or implications of these events. The Surveillance Test for the Boron Dilution Alarms was successfully completed before and after the events. No work had been performed on the Startup Channels between performances of the monthly Surveillance Tests. Additionally the boron samples required by Technical Specification 3. 1.2.7 ACTION a. 1 did not indicate any dilution of the RCS. The boronometer (CB) was also operable and the boronometer chart NRC Form 366A (Fr69)

. lb Cl

/6 NAG FORM 366A U.S. NUCLEAR REGULATOAY COIAMISSION (6 $ 9) API'ROVED OMB NO. 31500104 EXPIRES; 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COI.LECTION REOUESTI 50A) HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECOADS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P$ 301. U.S. NUCLEAR REGUI.ATOAY COMMISSION.'ASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31504)104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (I) DOCKET NUMBER (2) LEA NUMBER (6) PAGE (3)

YEAR SECVENTIAL REVISION NVMBER NVMBER Palo Verde Unit 2 o s o o o 52 989 0 0 8 01 06 OF 0 6 TEXT /// moro toto) iJ rtr/virtd, vtt tddrrr'oot/ iV/IC Form 366A'4/ (17) did not show any dilution of the RCS. Therefore, there was no, impact on the health and safety of the public.

I I I. CORRECTIVE ACTIONS:

'A. Immediate:

Startup Channel 2 was declared inoperable and surveillance test 36ST-9SE05 was performed satisfactorily. Startup Channel 2 was then declared operable.

B. Action to Prevent Recurrence:

The I&C Technician that performed the surveillance tests and the I&C Technicians that performed the independent verifi'cation were counseled. In addition, the procedure was changed to make the

'nstructions more explicit.

An investigation of this event was completed in accordance with the PVNGS Incident Investigation Program. The investigation did not identify any further corrective actions to be taken.

IV. PREVIOUS SIMILAR EVENTS:

No previous similar events have been reported.

NRC Form 366A (6$ 9)

0 0 S