ML19327B299

LER 89-006-00:on 890926,Procedure 34SV-SUV-019-2S, Surveillance Checks Did Not Fully Implement Requirements of Tech Spec Table 4.3.2-1.Caused by Personnel Error. Personnel Counseled & Procedure revised.W/891023 Ltr

ML19327B299
Person / Time
Site:	Hatch
Issue date:	10/23/1989
From:	Hairston W, Tipps S GEORGIA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
HL-796, LER-89-006-03, LER-89-6-3, NUDOCS 8910300121
Download: ML19327B299 (9)

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PLANT HATCH - UNIT 2

.NRC DOCKET 50-366 OPERATING LICENSE NPF-5 LICENSEE EVENT REPORT PERSONNEL ERROR RESULTS IN AN INADEQUATE EROCEDURE AND MISSED SURVEILLANCE L Gentlemen:

In accordance with the requirements of 10 CFR 50.73(a)(2)(i), Georgia Power Company is submitting the enclosed Licenste Event Report (LER) concerning some missed Technical Specifications surveillances. This

p. ' event occurred at Plant Hatch - Unit 2.

Sincerely, Al.W H. G. Hairston, III l- 'JJP/ct L

Enclosure:

LER 50-366/1989-006 l

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Mr. H. C. Nix, General Manager - Nuclear Plant  :

Mr. J. D. Heidt, Manager Nuclear Engineering and Licensing - Hatch ,

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Mr. L. P. Crocker, Licensing Project Manager - Hatch  !

U.S. Nuclear Reaulatory Commission. Reaion II Mr. S. D. Ebneter, Regional Administrator i Mr. J. E. Menning, Senior Resident Inspector - Hatch [

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On 9/26/89 at approximately 1400 CDT, Unit 2 was in the Refuel mode with the Reactor Pressure Vessel head removed, the cavity flooded, and all fuel removed from the core. At that time, non-licensed personnel determined '

procedure 34SV-SUV-019-25, " Surveillance Checks," did not fully implement i the requirements of Unit 2 Technical Specifications Table 4.3.2-1, item 1.g. and Table 4.3.6.4-1, item 12. Specifically, since 11/11/88, the channel check of Drywell High Range Radiation indicators 2011-K621A and B  ;

was being performed once per seven days instead of the required once per i day, and a monthly channel check was not being performed for the Drywell radiation parameter of recorders 2T48-R601 A and B. The indicators were i being calibrated and functionally tested at their required frequencies. ,

The root cause of this event is cognitive personnel error in that nonlicensed personnel failed to adequately incorporate Technical Specifications requirements into a major revision of a plant procedure '

made effective on 11 /11/88 and failed to identify the condition in subsequent procedure reviews.

Corrective actions for this event include counseling involved personnel and revising procedure 34SV-SUV-019-2S prior to Unit 2 startup to ensure performance of the surveillance when the iPistruments are required to be operable.

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Energy Industry Identification System codes are identified in the text as (EIIS Code XX).

SUMMARY

OF EVENT l On 9/26/89 at approximately 1400 CDT, Unit 2 was in the Refuel mode with ,

the Reactor Yessel Head removed, the cavity flooded, and all fuel removed from the core. At that time, non-licensed personnel determined ,

procedure 345V-SUV-019-25, " Surveillance Checks," did not fully

• implement the requirements of Unit 2 Technical Specifications Table 4.3.2-1, item 1.g, and Table 4.3.6.4-1, item 12. Specifically, since 11/11/88, the channel check of Drywell High Range Radiation indicators 2011-K621A and B (EIIS Code IL) was being performed only once per seven -

days instead of the required once per day, and a monthly channel check was not being performed for the blue pen, the Drywell radiation parameter, of the Drywell High Range Pressure / Radiation recorders 2T48-R601A and B.  ;

The indicators were being calibrated and functionally tested at their required frequencies and had not experienced any significant problems,  :

as indicated by th'Is testing, over the past three years. The recorders' red pens, the Drywell pressure parameter, were being checked once per day as required. Any gross failure of the blue pens would have been '

noted at this time. Based on this information, it is concluded that the instrumentation was capable of performing its safety function when required.

The root cause of this event is cognitive personnel error. Procedure i 34SV-SUV-019-2S was issued 11/11/88 following a major revision with the incorrect frequency for the channel check of indicators 2D11-K621 A and B and with no requirement to perform a channel check of the blue pen for recorders 2T48-R601A and B. Involved personnel were made aware of this l- event and the consequences of their errors. The procedure will be l revised prior to Unit 2 startup.

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• DESCRIPTION OF EVENT l' On 9/26/89, Nuclear Safety and Compliance (NSC) Department personnel l were reviewing Unit 2 Technical Specifications Table 4.3.2-1, " Isolation Actuation Instrumentation Surveillance Requirements." The review was being performed as part of the validation of the plant's Commitment Tracking System Data Base. This validation ef fort includes a review ,

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l3 or 0l7 7 gut L sing apose a se,vegg use m NC 4en M4th of the data base entry for each Technical Specifications surveillance I requirement to casure all procedures which implement each surveillar'ce requirement are included. It was discovered that procedure 34SV-SUV-019-2S did not fully implement the requirements of Unit 2  :

Technical Specifications section 4.3.2.1. Table 4.3.2-1, item 1.g, '

Drywell Radiation High indicators (2011-K621 A, B). The procedure -

required a channel check (a qualitative assessment of channel behavior during operation by observation) of these two indicators to be performed once per seven days whereas Unit 2 Technical Specifications requires the channel check to be performed once per day.

During the investigation of this event, NSC personnel discovered procedure 34SV-SUV-019-2S also did not fully implement the requirements of Unit 2 Technical Specifications section 4.3.6.4. Specifically, item 12 of Table 4.3.6.4-1 " Post-Accident Monitoring Instrumentation Surveillance Requirements," requires a monthly channel check for the blue pen, the Drywell radiation parameter, of the Drywell High Range .

Pressure / Radiation recorders 2T48-R601 A and B. Procedure 34SV-SUV-019-2S did not require the channel check to be performed.

However, the procedure did require a monthly channel check of the red pen, the Drywell pressure parameter of the recorders. Any gross failure '

of the blue pen would have been noted during this channel check.

Unit 2 Technical Specifications Amendment No. 78, dated 7/14/87, added item 1.g to Unit 2 Technical Specificaticos Table 4.3.2-1. Among the new requirements associated with this addition was the requirement to perform a channel check of indicators 2D11-K621 A and B on a daily basis. At the time this amendment was issued, these indicators were already contained in Table 4.3.6.4-1, item 12. This table required only a monthly channel check of the indicators. However, a daily channel check was already required in procedure 34G0-SUV-002-25, " Surveillance Checks," to mev.t the requirement. Since this frequency also met the new requirements of Table 4.3.2-1, item 1.g it was determined that the procedure did not require revision and the reference to the new Technical Specifications requirement was not added to the procedure. ,

in July 1988, a major revision of procedure 34GO-SUV-002-2S was initiated. As part of this revision, it was re-numbered to 34SV-SUV-019-25 and was made effectivc 11/11/88. During the revision process, the frequency at which the channel check of indicators 2011-K621 A and B was required to be performed was changed from daily to weekly. This frequency still met the requirements of Table 4.3.6.4-1, item 12 (referenced in 34G0-SUV-002-2S), but did not meet the requirements of Table 4.3.2-1, item 1.g (not referenced in 34G0-SUV-002-2S). The need to include Table 4.3.2-1, item 1.g. as a ,

reference in the procedure was identified during the technical review of the revision. However, the need to change the proposed frequency of the

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therefore, did not appear in versions of the procedure reviewed by NSC and the Plant Review Board. Consequently, the condition was not identified during these reviews.

Also during the major revision, the requirement to perform a channel check of the blue pen for recorders 2T48-R601 A and B was omitted from the procedure. The channel check had been required by procedure 34GO-SUV-002-2S to be performed daily. This error was not discovered in any of the procedure reviews.

CAUSE OF THE EVENT The root cause of this event is cognitive personnel error by the non-licensed procedure writer and the technical reviewer. The writer incorrectly changed the frequency of the channel check for indicators 2011-K621 A and B when writing procedure 345V-SUV-019-25. Also, the writer failed to ensure incorporation of the technical reviewer's comment concerning the reference to Table 4.3.2-1, item 1.g. The writer also incorrectly deleted the channel check of the olue pen of recorders 2T48-R601A and B. The technical reviewer failed to note the incorrect frequency when he commented on the reference to Table 4.3.2-1, item 1.g.

Contributing to this event was personnel error by non licensed NSC reviewers. During review of procedure 345V-SUV-019-25, the NSC reviewer did not note the procedure did not require a channel check of the blue pen of recorders 2T48-R601 A and B. This error appears to have been caused, in part, by the fact Table 4.3.6.4-1, item 12, required a channel check of both indicators 2D11-K621 A and B and recorders 2T48-R601A and B. The MPL numbers of these instruments, however, were listed only in Table 3.3.6.4-1. Indicators 2011-K621 A and B provide a direct input to the blue pen of recorders 2T48-R601A and B, respectively, and it is unusual to have to check both sets of instruments. This is the only item in this table which requires a channel check of both the indicator and its associated recorder. The procedure did require a weekly channel check of the indicator. The NSC reviewer checked this against Table 4.3.6.4-1, item 12, and felt the requirements were met.

Also contributing to this event was a less than adequate Technical Specifications amendment review procedure in 1987. This procedure did not require procedure references to be reviewed. Consequently, the reference to the new Table 4.3.2-1, item 1.g. was not added to procedure l 34G0-SUV-002-2S when Amendment No. 78 was issued. Had the reference been in 34G0-SUV-002-25 when it was revised in July 1988, it is possible the channel check frequency for indicators 2D11-K621 A and B would not have been incorrectly changed during the major procedure revision.

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REPORTABILITY ANALYSIS AND SAFETY ASSESSIENT This report is required by 10 CFR 50.73(a)(2)(1) because a condition existed which was prohibited by the plaat's Technical Specifications.

Specifically, the surveillance requirements of Unit 2 Technical Specifications sections 4.3.2.1 and 4.3.6.4 were not fully met. Since 11 /11/88, the channel check for indicators 2D11-K621 A and B was performed once per seven days instead of once per day as required by Section 4.3.2.1 and the channel check for the blue pen of recorders

n. 2T48-R601 A and B was not being performed as required by Section 4.3.6.4.

The post-accident monitoring instrumentation, of which the above indicators arid recorders are a part, ensures that sufficient information is available on selected plant parameters to monitor and assess important variables following an accident. The indicators 2D11-K621 A and B also provide an isolation signal to the primary containment purge and vent isolation valves. This isolation provides protection in the event of low rates of reactor coolant leakage and releases to the drywell .

In this event, the channel check for indicators 2011-K621 A and B was being performed less frequently than required since 11 /11/88. However, the indicators were being functionally tested monthly and calibrated once every 18 months as required by the Unit 2 Technical Specifications. No problems have been found during these surveillances. In addition, a review of maintenance history for these instruments shows no significant problems for the past three years.

Therefore, it is concluded that these instruments would have functioned as required in the unlikely event of an accident.

Also in this event, a channel check had not been performed for the blue pens on post-tecident Drywell High Range Pressure / Radiation recorders 2T48 R601A and B since 11/11/88. They were, however, calibrated once every 18 months as required. Additionally, the red pens on recorders 2T48-R601 A and B were checked daily and the recorder chart paper was stamped each shif t. The channel check of the recorders' red pen reading L

and the stamping of the recorders' paper should have alerted the operator to any gross failures of the Drywell High Range Radiation blue pens. Moreover, drywell radiation levels could have been determined from post-LOCA Gamma Radiation indicators 2011-K622A and D (EIIS Code IL). These indicators are covered by item 8 of Unit 2 Technical Specifications Table 4.3.6.4-1. They were checked and calibrated as J required, therefore, they were operable and available should the

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Based on the above discussion, .it is concluded this event had no adverse impact on nuclear safety. This analysis is applicable to all power level s.

l CORRECTIVE ACTIONS The Drywell High Range Radiation. instruments were declared inoperable and Limiting Condition for Operation 2-89-458 was written to ensure the l required surveillance is performed prior to t,tartup (i.e., when the instruments are required to be operable).

Procedure 34SV-SUV-019-2S will be revised prior to Unit 2 startup (approximately 12/20/89) to correct the frequency for the performance of

- the channel check of indicatorr. 2011-K621 A and B and to include the L required channel check of the blue pen of recorders 2T48-R601 A and B.

Procedure 34SV-SUV-019-15. " Surveillance Checks," was checked against

- the equivalent Unit 1 Technical Specifications and no problems were found.

Involved personnel have been counseled regarding the significance of i

this event and the need for constant attention to detail.

The deficiencies in the amendment review procedure were identified in 1987, af ter Amendment No. 78 was issued. (The identification of the procedure's deficiencies was not related to this amendment.) A major revision of this procedure was undertaken resulting in a new Adninistrative Control Procedure. The new procedure, 40AC-REG-003-05,

" Licensing Document Revision and Clarification Program " was effective 12/14/87. This procedure contains specific items to review when comparing Technical Specifications amendments against procedures for needed revisions and, as noted previously, includes a check of Technical Specifications references.

ADDITIONAL INFORIMTION No systems other than Drywell High Range Radiation indicators 2011-K621 A and B and recorders 2T48-R601A and B (blue pen only) were affected by this event.

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Previous similar events have occurred in which plant procedures have not adequately incorporated the surveillance requirements of Technical Specifications. These were reported in the following Licensee Event Reports:

50-321/1989-011 dated 09/26/89 50-321/1989-009 dated 09/21/89 50-321/1989-005 dated 04/21/89 50-366/1989-002 dated 03/14/89 50-321 /1988-019 dated 01/16/89 50-366/1988-002 dated 03/18/88 l

l Corrective actions resulting from the previous similar events included

l. counseling of involved personnel, revisions to appropriate procedures, the revision of plant procedures, a review of an amendment involved in a previous similar event, and a review of a sample of surveillance procedures to ensure compliance with Technical Specifications

,- Surveillance requirements. Revisions to involved procedures, the review l of an amendment, and the counseling of involved personnel would not have prevented this event since the procedures, amendment and personnel were

. unique to those events. The review of a sample of surveillance procedures would not have prevented this event because this procedure was not among the sample of procedures re.'iewed.

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