ML20046A114

LER 93-007-00:on 930609,determined That Daily Instrument Checks Required by TS Were Not Included in Operator Rounds. Caused by Mgt & Human Factors Weakness.Ts Proposed Change & Amend Issue Process Will Be performed.W/930716 Ltr

ML20046A114
Person / Time
Site:	Vermont Yankee
Issue date:	07/16/1993
From:	Wanczyk R VERMONT YANKEE NUCLEAR POWER CORP.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-93-007, LER-93-7, NUDOCS 9307260211
Download: ML20046A114 (5)

Text

.. . . .

3 VERMONT YANKEE NUCLEAR POWER' CORPORATION P.O. Box 157, Governor Hunt Road 3; s

'/ \ Vernon, Vermont 05354-0157

.( Y I .'

x. _-( (802) 257-7711 3 ,.-

July 16, 1993 U.S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555

REFERENCE:

Operating License DPR-28 Docket No. 50-271 Reportable Occurrence No. LER 93-07 Dear Sirst As defined by 10 CFR 50.73, we are reporting the attached Reportable Occurrence as LER 93-07. A seven-day extension was granted on 7/9/93 by Eugene Kelley of Region I for this LER.

Very truly yours, VERMONT YANKEE NUCLEAR POWER CORPORATION

/ .

Robert Wanczyk r Plant lianager cc: Regional Administrator USNRC Region I 475 Allendale Road King of Prussia, PA 19406 230040 9307260212 930726 PDR S

ADOCK 05000272 pon I.1

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WRC Form 366 U.S. NUCLEAR SEGULATORY COMMISSION APP 30VED OMS No. 3150-0104- I (6-89) EXP!2ES 4/30/92 ESTIMATED BURDEN PER RESPONSE TO C0t; PLY WITH THIS ]

INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD i COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P 350), U.S. NUCLEAR PEGULATORY COMMISSION, WASHINGTON DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (3160-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20603.

FACILITY NAME (1) DOCKET NO. (2) PAGE (3)

VERMONT (ANKEE NUCLEAR POWER $ FAT 10N Ol5j.0l0l0l2l7l1 0 1 OF 0 4 TITLE (4)

FAILURE TO PERFORM DAILY INSTRUMENT CHECKS DUE TO MANAGEMENT AND HUMAN FACTORS WEAKNESS EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)

MONTH DAY YEAR YEAR SEQ # REV # MONTH DAY YEAR FACILITY NAMES DOCKET NO (S) ,

0 5 0 0 0  !

l 0 6 0 9 9 3 9 3 -

0 0 7 -

0 0 0l7 1 6 9 3 0 5 0 0 0  !

OPERATING THIS REPORT IS SUBMITTED PURSUANT TO REQ'MTS OF 10 CFR i: CHECK ONE OR MORE (11)

CloDE (9) N 20.402(b) 20.405(c) 50.73(a)(2)(iv) 73.71(b)

POWER 20.405(a)(1)(1) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c) )

LEVEL (10) 100 j 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vil) OTHER: 1

. . ... . . ... 20.405(a)(1)(lii) X 50.73(a)(2)(i) 50.73(a)(2)(viii)(A)

. . . . . . 20.405(a)(1)(iv) 50.73(a)(2)(fi) 50.73(a)(2)(viii)(B)

...... . .. . 20.405(a)(1)(v) 50.73(a)(2)(lii) 50.73(a)(2)(x)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NO.

AREA CODE ROBERT J. WANCZYK, PLANT MANAGER 8l0l2 2lSl7l-l7l7l1l1 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE SYST COMPONENT MFR REPORTABLE CAUSE SYST COMPONENT MFR REPORTABLE TO NPROS .. TO NPRDS ....  ;

NA NA ... NA NA .... l l { l l l l l l l l l l l l 1

l l l l 1 SUPPLEMENTAL REPORT EXPECTED (14) EXPECTED MO DAY YR I SUBMISSION i DATE (15)  !

YES (!f yes, complete EXPECTED SUBMISSloN DATE) X NO l l l ABSTRACT (Limit to 1400 spaces, i.e., approx. fif teen single-space typewritten lines) (16)

On June 9,1993 it was determined that the Daily Instrument Checks required by Technical Specifications Table 4.2.1~were not included in the Operators Rounds for the Auxiliary Power Monitor and the Pump Bus Power Monitor for the Core Spray system and the Low Pressure Coolant injection system. On June 21,1993 additional Daily Check omissions from the Operator Rounds were found in Table 4.2.1 for the High Drywell Pressure instrumentation in the Emergency Cote Cooling System, and on June 23,1993 in Table 4.2.2 for the High Drywell Pressure instrumentation in the Primary Containment Isolation System and Table 4.2.9 for the Reactor Core isolation Cooling Lcgic Bus Power Monitor.

The root cause of these events has been determined to be Management weakness in evaluating surveillance requirements with contributing causes of Human Factors and Personnel Error due to a lack of instrument tag numbers in the Tech Spec Tables.

Immed: ate corrective actions consisted of revisions to the " Conduct of Operations and Operator Rounds

• Procedure , issuance  ;

of Standing Order # 8, and expanded review for potential problems with other Daily Instrument Checks in this TS Section. A 1 continuing effort will review all other TS Sections and will result in issuance ci an LER supplement and TS revisions if required.

NRC Form 366 ]

(6 89) .

1

w NCC Form 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMS NO. 3150-0104 (6 89)' EXP!RES 4/30/92 4

ESTIMATED BURDEN PE2 RESPONSE TO COMPLY WITH THIS .

-INFORMATION COLLECTION REoVEST: 50.0 HRS. FORWARD LICENSEE EVENT REPORT (LER) COMMENTS REcARDING BURDEN ESTIMATE TO THE RECORDS AND TEXT CONTINUATION REPORTS MANAGEMENT BRANCH (P-350), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (3160-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20603.

FACILITY NAME (1) DOCKET No (2) LER NUMBER (6) PAGE (3)

YEAR SEQ # REV #

VERMONT YANKEE NUCLEAR POWER CoRPORAT!oN 9 3 -

0 0 7 -

0 0 0l5l0l0l0l2l7l1 0l2 0F 0l4 TEXT (If more space is required, use additional NRC Form 366A) (17)

Descrmtion of Event On June 9,1993 it was determined that the Daily instrument Checks required by Vermont Yankee Technical Specifications (TS)

Table 4.2.1 for the Auxiliary Power Monitor relay and the one of the two Pump Bus Power Monitor relays for the Core Spray system (CS) (Ells =BM) and the Low Pressure Coolant injection system (LPCI) (Ells = BO) were not being met by the daily check being conducted under the Operator Rounds. The CS Pump Bus Monitor consists of relays 14-K3 A&B and 14-K4 A&B, the CS Aux. Power Monitor consists of relays 14-K1 A&B. The LPCI Pump Bus Power Monitor consists of relays 10-K3 A&B and 10-K4 A&B, the LPCI Aux. Power Monitor consists of relays 10-K1 A&B. This concem was identified during a Biennial review of a Maintenance relay cal;bration procedures.

On June 21,1993 during a follow up engineering review, it was determined that the Daily Instrument Checks in accordance with TS Table 4.2.1 for the High Drywell Pressure instruments in the Emergency Core Cooling System (ECCS) (Ells = BO) were also not included in the Operators Rounds. The ECCS High Drywell Pressure instruments consists of Analog Trip Cards for PT.10-101 A(M) through D(M).

On June 23,1993 during additional engineering review, it was determined that the Daily Instrument Checks in accordance with TS 4.2.2 for the High Drywell Pressure instruments in the Primary Containment Isolation System (PCIS) (Ells =BD) were also not being performed. The PCIS High Drywell Pressure instruments consists of Analog Trip Cards for PT-5-12 A(M) through.

D(M). At the same time it was determined that the Daily instrument Check in accordance with TS Table 4.2.9 were not being performed for the Reactor Core isolation Cooling system (RCIC) (Ells = BN) Logic Bus Power Monitor. The RCIC Logic Bus Power Monitor consists of relay 13-K36.

The Daily Instrument Checks of the Aux Power Monitor and Pump Bus Power Monitors in the CS, and LPCI systems were thought to be satisfied by checking the annunciator for Bus / Logic Fail, a further review determined that the relays in question did not feed the annunciator window, these relays are original plant equipment since start-up in 1972. The High Drywell Pressure instrument checks in the PCIS and ECCS systems were installed in 1984 under the Analog Trip modification Phase 11 and were not identified in the Operator Round. The RCIC Logic Bus Power Monitor table was added to the TS Tables in November 1988 under Amendment 111, this relay is annunciated in the Control Room, but was not listed in the Operators P.ounds for daily checks.

Cause of Event These events will be discussed in three separate areas for specific root cause evaluation. The first concern is the Aux and Pump Bus Power Monitors. These daily instrument check requirements are original requirements from initial plant start-up. The root cause most applicable to these checks is due to misinterpretation in that the opetators were checking an annunciator to satisfy this requirement and were not aware that the second Pump Bus Power Monitor relay or the Aux Power relay did not feed the annunciator window. This alarm window is fed from the first of two Pump Bus Power Monitor relays and is not associated with the Aux Power Monitor relay.

The second concern is the Drywell Pressure instrumentation for the ECCS and PCIS Analog Trip systems. These instruments were installed in 1984 as the second phase of the Analog Trip system. The initial Analog Trip system design change added several daily instrument checks on the Operators Round Sheets. However, this phase of design provided revised TS Tables requirements for the additional daily instrument checks but did not list the Operators Round Sheet procedure as affected by the design. The Proposed TS Change No.103 and Plant Design Change 82-08 which implemented the new daily instrument checks received a detailed review dunng the design review process which did not discover the missing procedure requirements.

This root cause is that the level of review in 1982 was not adequate to locate the missing procedure change for daily instrument checks. The required functional and Cahbrations procedure changes were adequately addressed during the review process and were implemented in the Surveillance Tracking system.

NRC Form 366A (6-89) =

l. . .. . _.

,- . +

NRC Form 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMS NO. 3150 0104 (6-89) EXP]RES 4/30/92 3

. ESilMATED BURDEN PER RESPONSE TO COMPLY WITH THIS l

• INFDRMATt0N COLLECTION REQUEST: 50.0 HRS. FORWARD .

LICENSEE EVENT REPORT (LER) COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND TEXT CONTINUATION REPORTS MANAGEMENT BRANCH (P 350), U.S. NUCLEAR REGULATORY COMMISSloN, WASHINGTON DC 20555, AND To THE PAPERWORK REDUCTION PROJECT (3160-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20603.

FACILITY NAME (1) DOCKET NO (2) LER NUMBER (6) PAGE (3)

YEAR SEo # REV #

9 7 0 3 0 0 0 0l3 0F 0l4 VERMONT YANKEE NUCLEAR POWER CORPORATION 0l5l0l0j0j2l7l1 TEXT Of more space is required, use additional NRC Form 366A) (17)

The third concem is the RCIC Logic Bus Power Monitor. This TS change was driven by an NRC requirement to establish a new TS Table for RCIC actuation logic surveillance requirements in 1988. This requirement which added a daily instrument check had not existed prior to this time, however, the annunciator for the RCIC Logic Bus Power Monitor was original plant design.

These changes in the new TS Table were reviewed under the TS Proposed Change No.145, however the review did not identify the need to add the Daily instrument Check to the Operator Round Sheet procedure. This relay is annunciated in the Control Room as a valid indication of availability and equipment operability however the specific daily instrument check in the TS tables was not documented in the Operators Rounds sheets. This root cause is attributed to personnel error in that when the revision was made to TS, the daily check requirement was not incorporated into plant procedures.

Severat efforts have been initiated since 1988 to ensure that the required TS surveillance requirements are being performed.

The Technical Specsfications tables were extensively reviewed by outside contractors for compliance with the surveillance requirement as a result of an NRC Inspection. However, the objective of the review was to ensure that all surveillance procedures addressed the tests requinng scheduling. These procedures are specifically listed in the 4000 series procedures for

" Surveillance Procedures" The daily instrument checks are listed in the General Plant Administrative and Operating Procedure 1 as AP 0150 and since the daily checks are not scheduled they were not included in this review. This effort did not identify the need to address the daily instrument checks due to human factors in that the efforts was originated with concerns on the Surveillance List which is governed by the 4000 series surveillance procedures.

In 1992, in response to LER 91-16 Operations performed a review of all Operations Department Daily Instrument Checks to verify that the specific instruments identified in the TS were the instruments actually being checked. This review was performed using the Operations procedure as the starting point to insure that specific instruments would be cross referenced in the procedure with the appropriate TS table reference. This ef fort did not identify the need to add the missing instrument checks due to human f actors weakness in that the clear definition of the device to be checked is not specified in the TS Tables.

The root cause of these events has been determined to be Management weakness in evaluating surveillance requirements with contnbuting causes of Human Factors and Personnel Error due to a lack of instrument tag numbers in the Tec.i Spec Tables.

Anafysis of Event The CS and LPCI system Aux. Bus Power Monitor relays are not annunciated in the Control Room, therefore a f ailure of these relays would not be immediately identified. However, if they were to fail, the result would be a initiation of the 0,5, or 10 second time delay start upon initiation of the ECCS pumps. The f ailure of these relays will not stop the pump from running as expected. These time delays are initiated to allow Dieselloading and are considered in our design basis for Loss of Normal j Power operation, l The CS and LPCI system Pump Bus Power Monitor relays have one of the two relays annunciated in the Control Room. The loss of the un annunciated relay would not be immediately identified. The loss of the un annunciated relay would not stop the pump start operation because both relay contacts are in parallel, either relay would allow pump start. The loss of both would be alarmed in the Control Room The ECCS High Drywell Pressure Master Trip Cards are located in the ECCS Cabinets in the Reactor Building on the 280 foot elevation. Each Trip Card has two annunciator alarms irt the Control Room. The two alarms are High Pressure and Gross Failure of the card. If the trip card drif ted high an alarm would annunciate in the Control Room, if the card failed an alarm would also annunciate and the card would need to be checked to determine the f ailure. However, if the card should drif t low, no alarm would be annunciated and the card must be checked to verify accurate pressure indicat;on. These cards are redundant to each other on the two different trains of ECCS, therefore the single f ailure of one card would still allow high drywell pressure initiation for the ECCS system. )

1 I

NRC Form 366A (6-89)

I

1. 4

• NRC ]Pora 366A U.S. NUCLEAR REGULA'! DRY COMMISSION APPROVED OMS NO. 3150-0104 i (6-69) ~

EXPIRES 4/30/92 ESTIMATED BURDEN PER RESPONSE 'ID COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD

' LICENSEE EVENT REPORT (LER) COMMENTS REGARDING BURDEN ESTIMATE 'ID THE RECORDS AND TEXT CONTINUATION REPORTS MANAGEMENT BRANCH (P-350), U.S. NUCLEAR REGULA'! DRY COMMISSION, WASHINGTON T 20555, AND 'ID THE PAPERWORK REDUCTION PRCkrECT (316, 3104), OFFICE OF MANAGEMENT AND BUDGET, WASHING'!DN, DC 20603.

FACILITY NAME 11) DOCKET NO (2) LER NUMBER (6) PAGE 13)

YEAR SEQ t REV 6 VERNONT YANKEE NUCLEAR POWER CORPORATION 0l5l0l0l0l2l7l1 9l3 -

0l0l7 -

ol0 0l4 or 0l4 TEXT (if more space is required, use additional NRC Form 366A) (17)

The PCIS High Drywell Pressure Master Trip Cards are located in the RPS Cabinets in the Reactor Building on the 280 foot elevation. Each Trip Card has two annunciator alarms in the Control Room. The two alarms are High Pressure and Gross Failure of ths card, if the trip card drifted high an alarm would annunciate in the Control Room, if the card failed an alarm would also annunciate and the card would need to be checked to determine the failure. However, if the card should drift low, no alarm would be annunciated and the card must be checked to verify accurate pressure indication. These cards are redundant to each other on the different trains of PCIS, therefore the single failure of one card would still allow high dryweX pressure initiation for the PCIS system.

The RCIC Logic Bus Power Monitor relay is annunciated in the Control Room and its failure would be known immediately, Corrective Actions immediate Corrective Actions

1. On June 9,1993 the Operations Dept. issued Standing Order No. 8 to visually verify the relay status daily for the CS and LPCI Pump Bus Power Monitor and Aux. Power Monitor relays.

2. On June 10,1993 the Operations Dept. revised procedure AP 0150 to include standing order No. 8 for the Aux Power Monitor and Pump Bus Power Monitor.

3. On June 21,1993 Procedure AP 0150 was revised to include ECCS High Drywell Pressure instrumentation daily checks for PT-10-101 A through D.

4. On June 23,1993 Procedure AP 0150 was revised to include PCIS High Drywell Pressure instrumentation daily checks for PT-5-12 A through D. In addition AP 0150 was also revised to include verification of annunciator window 4-V.5 for the RCIC Logic Bus Power Monitor is de-energized.

Lona Term Corrective Actions

5. All Daily instrument Checks listed in TS Tables will be verified as being performed, with respect to the appropriate device or instrument. This verification will be completed by 8/31/93.

6. If the above review finds any other Daily Instrument Checks that are not been performed, a supplement to this LER will be submitted if required.

7. A review of the TS required Calibrations and Daily Instrument Checks applied to devices which are not instruments will be performed and appropriate TS revisions will be submitted as required.

B. A review of the Design Change process, Technical Specification Proposed Change and Amendment issue process will be performed to establish a formal review process to ensure appropriate procedures are revised. This review will be completed by 2/28/94

9. In response to a previous concern we wiu perform a review of procedures that implement TS surveillance requirements to ensure management's expectations in this area are being met. This review will begin in the near future and will address such items as the intent of the TS surveillance requirements, assumptions, trending, administrative limits and clarity of procedural instructions.

Additional Information A review of past LER's for five years for similar occurrences identified LER 91-16 " Failure to Perform Daily Instrument Checks Due to Tech Spec Human Factors Weakness".

NRC Form 366A (6-89)

L