05000333/LER-1998-001, :on 980128,invalid Isolations of Reactor Building Ventilation & Associated Actions,Occurred.Cause Not Determined.Revised Procedure ODSO-34 to Ensure That Prior Independent Reviews of TS Performed

:on 980128,invalid Isolations of Reactor Building Ventilation & Associated Actions,Occurred.Cause Not Determined.Revised Procedure ODSO-34 to Ensure That Prior Independent Reviews of TS Performed

ML20203L032
Person / Time
Site:	FitzPatrick
Issue date:	02/26/1998
From:	Michael Colomb, Richard Plasse POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
JAFP-98-0077, JAFP-98-77, LER-98-001, LER-98-1, NUDOCS 9803050308
Download: ML20203L032 (7)

LER-1998-001, on 980128,invalid Isolations of Reactor Building Ventilation & Associated Actions,Occurred.Cause Not Determined.Revised Procedure ODSO-34 to Ensure That Prior Independent Reviews of TS Performed

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(iv), System Actuation 10 CFR 50.73(a)(2)(iv)(B), System Actuation 10 CFR 50.73(a)(2)(v), Loss of Safety Function
3331998001R00 - NRC Website

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James A. FitzPatrick Nuclear Power Plant 268 L Ae Rold P.O. Box 41 Lycoming, New York 13093 315-34t 3840 4 NewYorkPower uicna,i a. Coioms

& Authonty s,1e execui,ve oscer February 26, 1998 JAFP-98-0077 United States Nuclear Regulatory Commission Attn: Document Control Desk Mail Station P1-137 Washington, D.C. 20555 Gubject:

Docket No. 50 333 LICENSEE EVENT REPORT: LER 98 001 Invalid Isolations of Reactor Building Ventilation and Associated Actions

Dear Sir:

This report is submitted in accordance with 10 CFR 50.73 (a)(2)(iv), (a)(2)(v)(C), and (a)(2)(v)(D).

There are no commitments contained in this report.

Questions concerning this re,nort may be addressed to Mr. Richard A. Plasse, Jr. at (315) 349 6793.

Very truly yours, MICHAEL. COLOMB MJC: RAP:las Enclosure cc:

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On 1/Md at 0946 hours0.0109 days <br />0.263 hours <br />0.00156 weeks <br />3.59953e-4 months <br /> with the plant operating at full power, a spurious invalid isolation signal of the Reactor Building Wlow Refuel Floor venthation exhaust radiation monitor 17RM-452B occurred. This resulted in an Engineered S:fety Featuro actuation with isolation of the Reactor Building Ventilation System, B side primary containment atmosphere sampling system and start of the B Standby Gas Treatment (SGT) System.

Radiation monitor 17RM-452B was removea from service for troubleshooting. At the time, the A SGT System was also r: moved from service for planned maintenance. This resu"""

a plant configuration where the remaining operable B SGT System did not have an auto-start function for a h "

mon condition in tne below Refuel Floor ventilation exhaust system.

i On 2/18/98, the plant was operating at full power ane-

her spurious isolation signal from 17RM-452B resulted in the same ESF actuation discussed above. Troublesho:

efforts have not determined the cause of the spurious isolations. A Root Cause Anatynis of the removal of 1-5452B from service during the A SGT maintenance indicates th:t procedure deficiencies, training deficiencies, and r operations staff failure to perform adequate independent reviews were contributing causes Correct!ve actions stuce procedure revisions, training, and plant staff review of the t:ssons teamed.

NRC FORM 360 (4%)

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NRc FORM M4A u.s. NUCLEAR REoVLAf oRY Commission (4 DS)

LICENSEE EVENP REPORT (LER)

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James A. FitzPatrick Nuclear Power Plant 05000333 02 OF 06 98 - 001 00 1nlA1 (It more space is requoted, use additoonal copoos of IVRc Form 366A) (11)

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EVENT DESCRIPTION

On January 2fA 1998, with the plant operating at 100 percent power, a scheduled 7-day Limiting Condition for Operation (LCO) was in progress on the A Standby Gas Treatment (SGT) (BH] System to allow planned maintenance activities. At 0946 hours0.0109 days <br />0.263 hours <br />0.00156 weeks <br />3.59953e-4 months <br />, a spurious invalid isolation signal of the Reactor Building (secondary containment) [NG) below Refuel Floor ventilation exhaust [VA) radiation monitor B occurred. The spurious isolation signe! resulted in isolation of the B side Reactor Building Ventilation System, the B side primary containment sampling system (BB), and the initiation of the B side SGT All equipment functioned as d2 signed ar.d the systems were restored to normal at 1030 hours0.0119 days <br />0.286 hours <br />0.0017 weeks <br />3.91915e-4 months <br />.

Tha Instrument and Control (l&C) Department was requested to remove the B Reactor Building below Refuel Floor ventilation exhaust radiation monitor (17RM-452B) from service. The monitor was removed from s2rvice at 1055 hours0.0122 days <br />0.293 hours <br />0.00174 weeks <br />4.014275e-4 months <br /> This action resulted in disabling the associated B side automatic isolations and the cuto start of the B side SGT from a high radiation condition in the below Refuel Floor ventilation exhaust monitor,17RM-452B.

At approximately 1500 hours0.0174 days <br />0.417 hours <br />0.00248 weeks <br />5.7075e-4 months <br />, the NRC Resident inspector questioned the remcval of 17RM 4528 from ssrvice while the A SGT system was removed from service for planned maintenance. The Work Control Csnter Supervisor and the Inspector determined that the remaining operable B SGT system would not have automatically initiated in the event of a high radiation condition in the Reactor Building below Refuel Floor exhaust path. The A Reactor Building below Refuel Floor exhaust ventilation monitor (17RM-452A) was op3rable and would have provided the A side isolations, but it initiates only the A SGT system (which was inoperable due to the planned LCO maintenance).

The Shift Manager verified the condition and isolated the Reactor Building and initiated B SGT system at 1549 hours0.0179 days <br />0.43 hours <br />0.00256 weeks <br />5.893945e-4 months <br />. The A SGT system was declered operable and the planned ma.ntenance LCO was exited at 1835 hours0.0212 days <br />0.51 hours <br />0.00303 weeks <br />6.982175e-4 months <br /> This resulted in the A SGT system being capable of automatic initiation from the operable below Rsfuel Floor exhaust radiation monitor (17RM-452A). At 1932 hcurs, the Reactor Building was unisolated, th3 ventilation system was returned to a normallineup, and the B SGT system was secured.

Initial troubleshooting of the radiation monitor (17RM-4528) attributed the spiking to a failed detector. l&C rcplaced the detector and properly returned the radiation monitor to service after satisfactory testing.

On February 18,1998, the plant was operating at full power when a spurious invalid isolation signal recurred on the same radiation monitor (17RM 452B). This resulted in the same Engineering Safety Feature (ESF) actuation discussed above. All equipment functioned as designed, l&C removed the monitor from service to support troubleshooting. Based on the ongoing design basis revie<v, as a precautionary measure, the op3rators maintained the Reactor Building isolated with the B SGT System in service during the troubleshooting efforts.

NRG i VRM 3%A (44t5)

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LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION F ACILITY NAME (1)

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PAGE (3)

MMV 50 James A, FitrPatrick Nuclear Power Plant 05000333 03 OF 06 98 - 001 00 1

k TEKT (Ilmore soace as requorvd. use additional copres of NRc form a66A) (11)

I EVENT CME Tha exact cause of the spurious radiation monitor trips has not been determined. The l&C Department conducted radiation monitor functional tests and cable connection integrity checks and found no failures. As i

of the dr.te of this report, l&C has replaced the radiation monitor detector and the power supply. A temporary modification has been initiated to monitor and record detector performance and power supply voltages. No abnormal operation of plant equipment preceding, or during the isolation Nents occurred.

On January 28,1998 due to the monitor spikes,17RM-452B was removed from service concurrent with the A SGT system being removed from service for a planned maintenance LCO. The Operations shift failed to r cognize the effects of removing this radiation monitor from service on the operable B SGT system. The Operators involved failed to perform independent reviews. The operators performed an inadequate review of th3 Technical Specifications (TS) when researching the LCO for 17RM-4528 removal from service. There w2re two contributing causes to the personnel error; (1) the procedure which removed the monitor from service, OP 31, " Process Radiation Monitoring System", and (2) the applicable TS referenced by the procedure, had no reference to the SGT system when removing a monitor from service. Specifically, R:diological Effluent Technical Specification (RETS) Table 3.101 allows the removal of one Reactor Building V ntilation Radiation Monitor with no required action.

As part of the Root Cause Analysis, a plant review was done to look for similar occurrences. This review id2ntified an event in January 1995 associated with the radiation monitor logic circuit. Although the event was not similiar, the impau of the monitor on the SGT system was questioned at that time. The plant review, documented in a memorandum, recommended a corrective action for applicable departments to review procedures that remove Reactor Building radiation monitors from service, and provide a caution against removing a radiation monitor with the opposite side of SGT out of service. This recommendation was not formally tracked or documented in the plant corrective action program.

During a review of protective tagout records performance since 1995, there were two other instances where a Rsactor Building radiation monitor was removed from service and the opposite side of SGT was inoperable, in both instances, the reactor was defueled with no fuel handling in progress and thus secondary containment dwas not required.

EVENT ANALYSIS

In both spurious isolation events, isolation of the B Reactor Building Ventilation System and B side Primary Containment Sampling System and initiation of the B SGT system, is reportable under provisions of 10 CFR 50.73 (a)(2)(iv) as an invalid ESF actuation not specifically exempted by 10 CFR 50.73 (a)(2)(iv)(B) due to th3 fact that the B side Primary Containment Sampling System valves are components of the containment isolation system in both events, the l&C Department completed troubleshooting efforts of the monitor system, replaced components, completed testing, and returned the monitor to service. The l&C Department continues to monitor component performance, as a definitive root cause of the spurious signal could not be dstermined, NMG t UMM K4A (4-95)

NRC FoMM 366A u.s. NUCLEAR REGULATORY Commission LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION F ACluTY NAME (1)

DoPKET LER NUMeER (6)

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EVENT ANALYSIS (cont'd.)-

The function of the Reactor Building ventilation exhaust radiation monitors is to provide continuous monitoring of the Reactor Building exhaust flow path to ensure gaseous releases are maintained below 10 CFR 20 limits, RETS Section 3.1 requires that at least one monitor be operable while the flow path is in service. The monitors also function to isolate the secondary containment and provide an auto-start to tha applicable SGT system. The plant configuration, during initial troubleshooting of the monitor (17RM-452B), resulted in a condition where the flow path was monitored for gaseous release as required by TS Section 3.1. In the event of a high radiation condition in the exhaust flow path, the Reactor Building exhaust system would have s2 cured automatically and provided the required "A" side isolations of the secondery contalnment. The SGT system, however, would not auto start on a valid isolation of the Reactor Builoing exhaust line. This could h:ve prevented or delayed diversion of exhaust flow to the plant stack (elevated release)in the event of an actual radiation release through the ventilation system. As a resuli, this condition is reportable pursuant to 10 CFR 50.73 (a)(2)(v)(C) and (D).

In addition to the Reactor Building ventilation exhaust monitor, several other auto start signals to the B SGT system were still operable. The B SGT system would have started upon occurrence of a high radiation signal from B Refueling Floor ventitation exhaust monitoring, a High Pressure Coolant injection initiation signal, high drywell pressure, or low react;r vessel level. Therefore, this event was not safety significant and it appears, based on initial engineering review, that the B SGT System wouid still have performed its required function for design basis accidents.

CORRECTIVE ACTIOE1 Plant management recognized that the Operations crew failed to identify the impact of removing 17RM-452B on related equipment during an existing planned LCO maintenance activity. -This is similar to weaknesses idsntified in a previous event (LER 97 011). A root cause analysis for this event was performed to ensure all performance issues and lessons leamed were identified. The root causes from this event were determined to be different than the previous event. The following corrective actions were identified to prevent recurrence of a similar event.

1.

Operations Department revised ODSO-34,"TS LCO and Maintenance Rule Unavailebility Tracking ",

to ensurs that independent reviews of TS are performed prior to removing equipment from service.

The LCO tracking sheet was also revised to include cansideration of the impact on existing LCOs when removing equipment from service. (Completed: 211 819 8) 2.

The Operations Manager has briefed the operators on the details of this event. The lessons learned from the root cause analysis will be reviewed by Operations management with the operating crews.

(Scheduled Completion Dato: 3/27/98)

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NRc FORM M4A U.s. NUCLEAR REGULATORY Commission LICENSEE EVERE REPORT (LER) 1 TEXT CONTINUATION FACILITY NAME (1)

DOCKET LE.R NUMBER (6)

PAGE (3)

"E$sTn" UI$t James A. FitzPatrick Nuclear Power Plant 05000333 05 OF 06 98 - 001 00 1EKT (11 rnore space os required. use estmonal copies of NRc Form 366A) (11) j CORRECTIVE ACTIONS (cont'd.)

3.

Actions will be taken to ensure that applicable Licensed Operator training material includes a caution on removing a Reactor BLilding radiation monitor from service with the opposite side of SGT removed from service. (Scheduled Completion Date: 7/1/98) 4.

Review and revise all applicable plant procedures to caution against removing a Reactor Building ventilation radiation monitor from service when the opposite SGT system is already removed from service. (Scheduled Completion Date: 6/1/98) 1 5.

An Equipment Failure Evaluation (EFE) of the subject radiation monitor (17RM 4528)is in progress.

Initialinvestigation indicated a bad detector. Based on the recurrence, this does not appear to be the only possible cause of the spurious signal. The monitor has been returned to service. l&C continues to monitor the radiation moritor performance, if the monitoring determines a different cause for the spurious signal, a supplement to this LER will be issued.

6.

Plant management initiated a licensing and design basis review of the Refuel Floor and Reactor Building ventilation radiation monitor systems as contained in the TS and FSAR. Based on the results of this review, a need for a TS amendrnent will be determined. (Scheduled Completion Date:

i 3/27/98) 7.

Plant personnel were briefed on the details of this event and the lessons learned, stressing the importance of tracking recommendations when identified by utilizing the plant corrective action program. (Completed: 2/26/98) 8.

Submit a Technical Specification change, if determined to be appropriate, to RETS Table 3.101, to address effects on Reactor Building isolations and Standby Gas Treatment actuation with the associated radiation monitor out of service. (Scheduled Completion Date: 6/30/98) l ADDITIOtLAL INFORMATION Prsvious Similar Events:

LER 92-023 reported a similar event where both Reactor Building ventilation exhaus. radiation monitors were made inoperable due to personnel errors.

LERs: 89 013,92-039,92 040,92-046, and 95-009 described similar unplanned engineering safety feature actuations. These events occurred during maintenance activities (i.e. Jumpering or lifted leads).

TRG FORV 156A (4 95) m

B YRITDEM 366A u s. NUCLEAR REGULATORV commission (4 95)

LICENSEE EVDTI REPORT (LER)

TEXT CONTINUATION FACILITY NAME (1) ll DOCKET LER NUMBl~R (6)

PAGE (3)

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ADDITIONAL INFORMAT!ON (cont'd.)

Extent of Condition: The root cause evaluation identified that licensed operators may not have been referring to TS bases conaistently when determining LCO actions. TS decisions were I

being based on TS LCO and surveillance requirements sections. In addition, RETS 1

Table 3.10-1 allowed removal of the radiation monitor. Other TS guidance could lead

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to similar events. This event has been reviewed by the operators to increase J

awareness and sensitivity to plant impact when removing equipment from service.

Procedure changes, formal training, and reviews of the lessons learned from the root cause are in progress. A licensing / design basis review was initiated to determine if a TS change is appropriate.

I The cause of the spurious signal has not been determined. A supplement to this LER

(

will be provided if a different cause is identified. Other radstion monitors will be reviewed if determined to be susceptible to the cause.

Recommended actions in a memorandum to file could have pre vented this event, but were not formally tracked in the plant corrective action program. Plant staff were briefed on this aspect to reinforce the need to track potential prob! cms to ensure appropriate corrective actions are completed.

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