ML20043C020
| ML20043C020 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 05/29/1990 |
| From: | William Cahill, Hood D TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LER-90-010, LER-90-10, TXX-90182, NUDOCS 9006010190 | |
| Download: ML20043C020 (9) | |
Text
.___ - _ - - -_ -
k
=
-- Log # TXX-90182-
~ 7~
File # 10200 903.4~
C~ C Ref. # 50.73:
78# ELECTRIC 50.73(a)(2)(1)
- w. J. c.wu #
Esecuruve b'k, President U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555
SUBJECT:
COMANCHE PEAK STEAM ELECTRIC STATION =
DOCKET NO.'50-445 DEVIATION FROM TECHNICAL SPECIFICATION -
LICENSEE EVENT. REPORT 90-010-00 Gentlemen: '
Enclosed is Licensee Event Report-90-010-000 for Comanche ' Peak Steam Electric ::
Station Unit 1, " Missed Special Condition Surveillances on Squaw Creek Reservoir Water Level Due to Personnel Error." =
Sincerely, William J. Cah 11, Jr.
DEN /daj Enclosure c - Mr. R. D. Martin, Region IV Resident Inspectors, CPSES (3) 9006010190 9005:29 PDR S
ADOCK 0500044D PDC
/f
-,-,,,,,,,u,,~,---, 9 s\
Enclosu're to TXX 90182 i NHC4 OHM 360 U.S. NUCLE AH REOULA108tV COMWl$ SON APPROVED OMB NO. 316401(r.
EKPIRES:4/3092 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 60.0 HRS. FORWARD COMMENTS RECARDINO
" " " " " ' " ' " " ' ' '"" "' " * ^ " "'" " "^"'*'*'"'
I LICENSEE EVENT REPORT (LER) 8 RANCH (P-630). U.S. NUCLEAR REGULATORY COMMISSION, WA8NNOTON.
30,20S56. AND TO THE PAPERWORK REDUCTION PROJECT (31160104). 1 0FFICE OF MANAGEMENT AND BUDGET.IMSHINOTON.DC.20603.
F acday Nano p) Docket Nunter (2) Page (3s l
COMANCHE PEAK - UNIT 1 0 l 510 l 010141415 1 I OF 10i8
'"* L*8 Missed sPECIAL CONolTION suRvEILLANcEs ON sOuAW CREEK REsERvolR WATER LEVEL l DUE TO PERSONNEL ERROR so- o . m a a ~ , te, r , n- o,.. m o e4.e.,- ,,os .
u ni,, O., v.a, v, I Wf ? Mr uone o., v, ggaa=* y{"531010 l l l 014 2 18 90 910 -
011l0 -
Olo 015 29 91) N/A to CFR <, ; , Check one or trmee of the losioengt ( t 4 0151010101 l I operce's Th 5*'
- suterwied pursuane to the seguiremeres o uoo. m 1 _ '* mom _ m4o6m _ maaxam _ nnu y' ,,,,, M406(aWiHi) _ 60.36(cH1) _ 60.73(aHa(v) _ 73.71(c)
E O I1 18 2a40smHijn sa3ewa _ 6amHaw _
Oih.,(specn in v Austrace b.4 NRC Form 306A) nd iri Teni.
.s ,,,,, 20.406(aH1H6il) 1 60.73(aXa(l) ,,, 60.73(aHa(vill (A)
%.,d
&:g#3 hyks.Ms
? S3sidtAp}! ,p _ 20.406(aH1)(h4 _
60.73;sHa@ _ 60.73mH2Hv60(B)
G to4 % m,M p %p 60 Matt?M Licensee Contact For The LER (i2) l**pewne Nunter Name Area Gode D. NORMAN HOOD SUPERVISOR COMPLIANCE 8 l 117 8 l 917 l- I 5 I 8 I 8 I 9 conW.i. On. u,,. F., E-ei c- r.iu,. one,eed m in. Renon (i m Cause $f. tem Corrponert Manufacture' No k O*"** O I** O*"'*"*"' M*""I**'"' T -
I I I I II I MNs@ l l l l 1l l WW lU l l I I II I _$i@$
Surplomonial Report Espected 04)
I l l l .I l l Espected Month Day M@ Year Subrvosalon C Yes (If yes. conpete Espected Subnseemn Datel b No l l l As.i,-utwioio . .t....oo, n.i.,wie.n n . ty,e.,,..o w n6)
On April 26,1990 at 0928 CST, the level of the Squaw Creek Reservoir (SCR) was determined to be 776.2 feet above Mean Sea Level by Control Room indication. The increased level was
, due to recent high amount of rainfall, in accordance with Technical Specification 4.7.6.b, the I
surveillance frequency of the SCR water level measurement was increased from at least once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> to at least once per two hours since the water level was above elevation 776 feet.
The increased surveillance frequency continued until the SCR level dropped to 775.99 ft, on April 30,1990 at 1610 CST.
The two hour surveillance interval, including the 25 percent extension allowed by Technical ,
Specification 4.0.2, was exceeded on two occasions; on April 28,1990 at 0600 CST and on
^
April 29,1990 at 1000 CST.
The missed surveillances resuited from personnel error. The procedure requirement to measure SCR water level at least every two hours was not met due to responsible personnel -
becoming involved in other duties. Corrective actions include procedure enhancements and counselling.
Enclosure to TXXo90182 Nscponu mt A U.S. NAL Asi H00M10HY CCeaWiMON APPROVED OMB NO. 8160 0104 CSTBAATED BUCEN PER RES E PLY WITH THIB INFORMATION LICENSEE EVENT REPORT (LER) ,To'C't,"j,l,",';
, ,'"l"fgo'l3, ,"*,
"* 8 g, ,g, TEXT CONTINUATION 0^%"ig,7,"M"lg*R'cTlL$%g,' o "-
DFFICE OF MANADEMENT AND BUDGET, WASHINGTON. DC. 20003.
Imossy Name (1) Dochei Nuntser (2) L[ R N9ert ' (6) Pape (3) 4 ear a Q*0gf My [g.
COMANCHE PEAK ,.uce.T UNI 1 0l51010101414l5 910 -
Ol110 -
010 012 OF 0lB i 4.. e . . . . . ..or .m .m n la DESCRIPTION OF WHAT OCCURRED I A. P1 ANT _OPEBAlltELCONDLTIONSEEEORElHE_Ej EMI On April 28,1900, Comanche Peak Steam Electric Station (CPSES) Unit 1 was in '
Mode 1, Power Operation, at approximately 18 percent power.
B. REPORTABLE EVENT DESCRIPTION (INCLUDING DATES I AND APPROXIMATE TIMES OF MAJOR OCCURRENCES)
Event Classification: Any operation or condition prohibited by the plant's Technical Specifications.
On April 26,1990, at approximately 0928, the level of the Squaw Creek Reservoir i (SCR) water level was determined to be 776.2 feet above Mean Sea Level by l Control Room indication. The increased level was due to recent high amount of rainfall, in accordance with Technical Specification (TS) 4.7.6.b, the surveillance frequency of the SCR water level measurement was increased from at least once per 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> to at least once per two hours since the waterlevel was above elevation 776 feet. The TS requirement for increased surveillance frequency is implemented by Abnormal Operating Procedure regarding acts of nature.
The two hour surveillance interval, including the 25 percent extension allowed by Technical Specification 4.0.2, was exceeded on two occasions; on April 28,1990 at 0600 and on April 29,1990 at 1000. This condition was discovered on April 30, 1990 at 1100.
On April 28,1990 at 0515, an Auxiliary Operator (Av) (utility, nonlicensed) responsible for reading SCR water level was dispatched by the Control Room to address problems in the switchyard. As a result, the 0600 reading was not taken.
The AO had discussions earlier during the shift with the Reactor Operator (RO)
(utility, licensed) concerning job assignments that may possibly conflict with the ability to take readings at SCR. Since the identified work for the AO at the start of the shift was not expected to exceed two hours, the ability for the AO to take the readings was decided to not be a problem.
Enclosure to TXX 90182 NrQFORW3%A U.S. NJCLL Ah HEQA A10RY COMW1SbON APPROWO OMB NO. 31S0104 l ESTIMATED BU8CEN PER RES E Y NTN THIS PFonuAftoN E'
LICENSEE EVENT REPORT (LER) ,73l,%,",5T',';, 17","'g, "*,'M7,*,%7,,
0 TEXT CONTINUATION 'fy[17;vs,Ng;AaRg,Tgc,ouus3gc o tn w n0 Hm;g w,
' MICE OF MANA0EWENT AND BUDGET,WA9HINGTON. DC.30603
> -., um w u.~ m an y re
_ l COMANCHE PEAK - UNIT 1 015101010l414l5 910 -
0l110 -
0IO OI3 OF 0l8 1 %..-.. . ~au-=A.nn >
On April 29,1990, a second AO responsible for reading SCR water level was i assigned other duties and realized that he would not be able to read SCR water level at 1000. The AO requested the Unit Supervisor (US) (utility, licensed) to assign another person to take the 1000 SCR water level reading. The US became involved in other duties and forgot to arrange for other personnel to take the reading.
As a result, the 1000 reading was not taken.
Procedures require that Technical Specification surveillances that are in progress as a result of an abnormal condition be documented during shift turnover. However, the failure to measure SCR water level at 0600 on April 28,1990 and at 1000 on April 29,1990 was not discovered during shift turnovers that occurred at 0700 and at 1500, respectlyely.
On April 30,1990 at 1610, SCR level was 775.99 feet and the surveillance frequency was returned to at least once every 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> in accordance with Technical Specifications.
l l C. STATUS OF STRUCTURES. SYSTEMS. OR COMPONENTS :
THAT WERE INOPERABLE AT THE START OF THE EVENT AND THAT CONTRIBUTED TO THE EVENT Not applicable - no structures, systems, or components were inoperable at the start of the event that have been determined to have contributed to the event.
D. CAUSE OF EACH COMPONENT OR SYSTEM FAILURE. IF KNOWN Not applicable - no component or system failures have been identified.
E. FAILURE MODE. MECHANISM. AND EFFECT OF EACH l FAILED COMPONENT Not applicable - no failed components have been identified.
1
Enclos'ure to TXX 90182 NRC FORM 366A U,$. NUCLEAR P.EWTOR@W$$ON 4ppqg g g g g4gigg
[SilMAftD sun 0CW PER RESPONSE TO COMPLY WITH THIS INFORMATON LICENSEE EVENT REPORT (LER) ge't?%,",'M*,'; ,* l"gegl,*,'MZ'gg, TEXT CONTINUATION ' %,Tg,"l,",T, '"l@^,'geT, ,"*n'OcW,@
2 arFCE OF MANAGEM[NT AND BUDGET WASHINGTON, DC.30603 7 nossy Noam p) :Joow Nmser m LE H NM*' @ Page(h
- ~ %*2 V ;tR*
l COMANCHE PEAK - UNIT 1 0151010l0l414l5 910 -
Ol110 -
010 014 OF 018 l i..n,mo . . . o .. . - m .- m,4.m o b
l F. FOR FAILURES OF COMPONENTS WITH MULTIPLE
( FUNCTIONS. LIST OF SYSTEMS OR SECONDARY ERNCTIONS THAT WERE ALSO AFFECTED ,
Not applicable no component failures have been identified, i
G. FOR FAILURES THAT RENDERED A TRAIN OF A SAFETY SYSTEM INOPERABLE. AN ESTIMATE QF THE ELAPSED TIME FROM THE DISCOVERY OF INOPERABILITY UNTIL THE TRAIN WAS RETURNED TO SERVICE Not applicable no failures were involved.
H. THE METHOD OF DISCOVERY OF EACH COMPONENT OR SYSTEM FAILURE OR PROCEDUR AL ERROR 1
A Shift Advisor (contractor, nonlicensed) discovered the missed surveillances while reviewing the Unit Log Book on April 30,1990 at 1100. SCR level was not ,
documented in the Unit Log Book on two occasions. Further investigation revealed that the surveillances had not been performed,
- l. CAUSE OF THE EVENT Root Cause The root cause of both missed surveillances was cognitive personnel error. The
, procedure requirement to measure the SCR water level at least every two hours was .
i not met due to the RO (utility, licensed) and the US (utility, licensed) not taking ,
l adequate measures to ensure compliance with the requirement when conflicting assignments for the AOs were identified. !
l Contributina Factor The failure to identify the missed surveillance at 0600 on April 28,1990 during shift turnover and take corrective actions was a contributing factor to the second event.
Not identifying the missed surveillance is attributed to the following factors:
Enclosure to TXX 90182 ,
NC FORW 386A U.S. NJOLE A4 HLQJLA10RY COVW%CN APPROVED OMB NO. 3%0104
- E8iluATED BURDEN PER RES NS T COMPLY WITH THl3 INFORMATION g3t,g,y*,; g, ggo, ,"* "g, jf,*'" ,
5*
^
LICENSEE EVENT REPORT (LER) ,
TEXT CONTINUATION f%"f,%1f,"f$","g,'Q*j"Ocy",',y DFFICE 05 MANAGEMENT AND BUDGET.WABHINGTON. DC.20603 Iacey Neste o) W N#te (i) LI A N 8 PM Ni COMANCHE PEAK 0151010101414 l5 910 -
Ol110 -
010 015 OF 018 1..u. . . . . e, Nn;r UNIT 1a. ., o r,
- 1) Procedures require that SCR level greater than or equal to 776 feet be measured every two hours and logged in the comment section of the Local Shiftly Surveillances Form, in lieu of logging the water level on the form, the two hour lake level readings were being recorded in the Unit Log Book. The Local Shittly Surveillances form covers a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> period and is passed on during shift turnover ;
after the form is approved by a US or Shift Supervisor (SS) (utility, licensed). The missed surveillance may have been discovered during shift turnover if the form
- had been utilized in accordance with procedure. >
- 2) Plant procedures require that TS surveillances that are in progress as a result of an abnormal condition be documented on shift turnover sheets. The surveillance of SCR water level was not consistently documented on the shift turnover sheets by the SSs, USs, and the ROs.
- 3) The Local Shittly Surveillances Form was less than adequate for logging the two hour interval surveillance readings. The two hour requirement was to be documented in the comment section of the form which is not formatted for data entry. A missed surveillance may not be readily apparent when reviewing the form for approval.
J. SAFETY SYSTEM RESPONSES THAT OCCURRED Not applicable there were no safety system responses and none were required.
i K. FAILED COMPONENT INFORMATION l
Not applicable - no failed components were involved. .
I l
ll. ASSESSMENT OF THE SAFETY CONSEQUENCES AND IMPLICATIONS OF THIS EVENT l
The two hour surveillance requirement of SCR water levelis to allow protective .
measures to be taken prior to water reaching 778 feet above Mean Sea Levelin accordance with Technical Specification 4.7.6.c. The SCR recorded levels never exceeded 778 feet from April 28 to April 30, therefore the surveillance requirement of Technical Specification 4.7.6.c was not applicable for this event. 778 feet corresponds to the elevation at which water could enter the electrical and control building and potentially l .
w -,. *a -
i Enclos'ure to TXX 90182 ,
unc,onu wA n NxuAn Roowou cwoum ,,,,,mo o uo. ,,,,,,, I CSTBAATED DURDEN PER RES SE Ptv WITH THIS PFORMATON LICENSEE EVENT REPORT (LER) $j,C'",",',,j8,';,'*l%'fo',o",*,^Mcg,'J,i'og, TEXT CONTINUATION **"*""'""*"'""'"^'"'*""'88""""'"-
- 30. PD666, AND TO THE PAPERWO8tK REDUCTION PROJECT (3120104) 7F CE OF MANAGEMENT AND SUDOET, WASHNOTON. DC. 20501
. ., m u., , ~ m a n~ <., e ,. a, va- 'ta.:? e :*r j
, ..um COMANCHE PEAR 01510l0l01414l5 910 -
Ol110 -
0IO Ol6 OF 018 l
- . .. wUN,IT
- mA 1
.n u, impact the Safety Chilled Water System (Ells:(KM)) if any equipment on the Circulating i Water System (Ells:(KE)) which is to be opened or is opened for maintenance were not l isolated from SCR by isolation valves or stop gates, or were not located at an elevation above 790 feet.
Surveillance measurements were missed on two separate occasions. The estimated ,
level on the first occasion, April 28,1990 at 0600, was 776.50 feet based on '
measurements taken the same day at 0400 and 0800 of 776.52 feet and 776.48 feet, respectively. The estimated level on the second occasion, April 29,1990 at 1000, was 776.23 feet based on measurements taken the same day at 0755 and 1235 of 776.24 feet and 776.21 feet, respectively. In addition, the highest level of 776.87 feet was recorded on April 26,1990 at 2204. From this point, the level was constantly decreasing.
Based on the above discussion, the event did not adversely affect the safe operation of CPSES Unit 1 or the health and safety of the public since the SCR level did not exceed >
778 feet.
Ill. .QORRECTIVE ACTIONS A. ACTIONS TO PREVENT RECURRENCE Root Cause Personnel were distracted by other duties. '
Corrective Action Personnel involved with both occurrences have been counselled on the importance of procedure compliance. In addition, the event was discussed during shift turnover meetlngs.
Contributina Factor 1 Procedure requirement to log SCR water levelin the comment section of the Local
- Shiftly Survelllance Form was not followed.
1 Ericlosure to TXX 90182 NRG FORM SfAA U.S. tfJCLE AR REGMTORY COMMGSON APPROVED OUD NO. 31640104 E KPIRE B. 4W92 E$TIMATED GU%EN PER r.'spONSE To COMPLY WITH THS INFORMATON
- E '*" "" 8 8" ""8 3 "*^* C""" 8 "E""*'" i LICENSEE EVENT REPORT (LER) BURDEN ESTIMATE 79 THE RECORDD AND REPORTS WANAGEMENT l TEXT CONTINUATION 5"^*"75""""^"""^'"YC""***"***"'"'" l
- 30. 20655. AND TO THE PAPERWORK REDUCTON PROJECT (31640104) j 3FFICE OF MANAGEMENT AND BUDGET. WASHINGTON. DC.20603<
f scany home (1) pas,se N,ite (n Lt R Nve fos Page (3)
Y ear .
EMgy 37M Qe i COMANCHE PEAK - UNIT 1 0151010101414l5 910 -
Ol110 -
0IO Ol7 OF 018 1 n. ~. . .. u.. uA .m n ,
l Corrective Action 1 i
The event will be reviewed by all on shift Control Room operators. The failure to meet I
procedure requirements will be noted.
Contributino Factor 2 Procedure requirement to address Technical Specification surveillances that are in progress as a result of an abnormal condition be documented on shift turnover sheets was not followed. 1 Corrective Action 2 The shift turnover sheets for the SS, Unit 1 Supervisor, Unit 1 RO and Unit 1 Balance of Plant Operation Operator have been revised to include a special condition surveillance section.
Contributino Factor 3 A form was less than adequate.
Corrective Action 3 Plant procedures have been revised to require the use of a newly developed special condition surveillance data sheet for SCR level. The data sheet is to be utilized when water level is greater than or equal to 776 feet and will be passed on during shift turnover, i
B. ACTION TAKEN ON GENERIC CONCERNS IDENTIFIED AS A DIRECT RESULT OF THE EVENT Generic Imolications l
Documentation requirements for other special condition TS surveillances in plant I procedures may not be formatted for functional usage. I y
l l
l l
4 a
E6 clos'ure to TXX 90182 Nng FonW 3%A U.S. NOCLEA4 REGULAT04 00WW4 SON gg' PROVED OWB NO. 3150 0104
, . EXPlRES:4'3092 ESTlWATED BURDEN PER RESPONSE TO COMPLY WITH THr8 PF04WATON
- ' C' *" "S *' ' 5" ""8 ' "*^* ""'** * *
- LICENSEE EVENT REPORT (LER) BURDEN E$flWATE TO THE RECORDS AND REPORTS WANAGEMENT TEXT CONTINUATION ""^*"""'"*""""""^'"' ""$$*"***"*'"-
- 30. 205$$. AND TO THE PAPE4 WORK REDUCTON PROJECT (31640104).
3FFCE OF WANA0EWENT AND BUDGET. WASHINGTON.DC. 20603.
t eossy Nesm. e) Dammt Nverse (23 LE R Desater 16: Pag. (3)
>.- w w m m COMANCHE PEAK - UNIT 1 0151010l014I4l5 910 -
Ol110 -
0IO Ol8 OF 0lB i..u. m . .- . . . 1,. em ore s. ., e n P
Corrective Action Procedures addressing special condition TS surveillances will be reviewed.
Additional data sheets identified which would further enable and document .
compliance with special condition surveillances will be added to plant procedures, :
as appropriate.
IV, PREVIOUS SIMILAR EVENTS There has been one similar event reported pursuant to 10CFR50.73 which involved a missed special condition surveillance.
LER 90 005 00 pertained to failure to perform a visualinspection of containment required by TS due to inadequate implementation of procedure requirements. Therefore, the corrective action taken in response to LER 90 005 00 would not have prevented this event.
V. OTHER All times provided are approximated and are Central Standard Time.
i 1
a c
I
?
i