ML17265A613

LER 99-002-00:on 990227,discovered That Surveillance Had Not Been Performed at Frequency,Per Ts.Caused by Personnel Error.Procedure O-6.13 Will Be Evaluated for Enhancement Documentation of Completion of ITS Srs.With 990329 Ltr

ML17265A613
Person / Time
Site:	Ginna
Issue date:	03/29/1999
From:	MECREDY R C, ST MARTIN J T ROCHESTER GAS & ELECTRIC CORP.
To:	VISSING G S NRC (Affiliation Not Assigned), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-99-002, LER-99-2, NUDOCS 9904080022
Download: ML17265A613 (10)

Text

~CATEGORYlaREGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ACCESSIONNBR:9904080022DOC.DATE:99/03/29NOTARIZED:NOFACIL:50-244RobertEmmetGinnaNuclearPlant,Unit1,RochesterGAUTH.NAME.AUTHORAFFILIATIONSTMARTIN,J.T.RochesterGas&ElectricCorp.MECREDY,R.C.RochesterGasFElectricCorp.RECIP.NAMERECIPIENTAFFILIATIONDOCKET05000244VISSING,G.S.EQ050002440NOTES:LicenseExpdateinaccordancewith10CFR2,2.109(9/19/72).

SUBJECT:

LER99-002-00:bn990227,discoveredthatsurveillancehadnotbeenperfohnedatfrequency,perTS.Causedbypersonnelerror.Procedure0-6.13willbeevaluatedforenhancementdocumentationofcompletionofITSSRs.With990329ltr.DISTRIBUTIONCODE:IE22TCOPIESRECEIVED:LTRENCLSIZE:TITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.RECIPIENTIDCODE/NAMEPD1-1PDINTERNAL:AEODSCENT~DRG-QMBNRR/DSSA/SPLBRGN1FILE01EXTERNAL:LSTLOBBYWARDNOACPOORE,W.NRCPDRCOPIESLTTRENCL112211111111111111'RECIPIENTIDCODE/NAMEVISSING,G.AEOD/SPD/RRABNRR/DRCH/HOHBNRR/DRPM/PECBRES/DET/EIBLMITCOMARSHALLNOACQUEENER,DSNUDOCSFULLTXTCOPIESLTTRENCL1111111111111111D0NTNOTETOALL"RZDS"RECIPIENTS:PLEASEHELPUSTOREDUCEWASTE.TOHAVEYOURNAMEORORGANIZATIONREMOVEDFROMDISTRZBUTIONLISTSORREDUCETHENUMBEROFCOPIESRECEIVEDBYYOUORYOURORGANIZATION,CONTACTTHEDOCUMENTCONTROLDESK(DCDjONEXTENSION415-2083FULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR18ENCL18 ANDg~gPjP~Pw~'qP~,P'V'(',e'>'4i<v'AA>>i".EsMarch29,1999U.S.NuclearRegulatoryCommissionDocumentControlDeskAttn:GuyS.VissingProjectDirectorateI-1Washington,D.C.20555

Subject:

LER1999-002,SurveillanceNotPerformed,DuetoPersonnelError,ResultedinViolationofTechnicalSpecificationsR.E.GinnaNuclearPowerPlantDocketNo.50-244

DearMr.Vissing:

Inaccordancewith10CFR50.73,LicenseeEventReportSystem,item(a)(2)(i)(B),whichrequiresareportof,"Anyoperationorconditionprohibitedbytheplant'sTechnicalSpecifications",theattachedLicenseeEventReportLER1999-002isherebysubmitted.Thiseventhasinnowayaffectedthepublic'shealthandsafety.Veryrulyyours,RobertC.Meredyxc:Mr.GuyS.Vissing(MailStopSC2)ProjectDirectorateI-1DivisionofReactorProjects-I/IIOfficeofNuclearReactorRegulationU.S.NuclearRegulatoryCommissionWashington,D.C.20555RegionalAdministrator,RegionI'U.S.NuclearRegulatoryCommission475AllendaleRoadKingofPrussia,PA19406U.S.NRCGinnaSeniorResidentInspector'79040800229'70329PDRADOCK050002448PDR NRCFORM366(91998).U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/charactersforeachblock)g(PF'IPJ(DQYOMBNOB3$50$IPWILS0+63@2001infotmaUoncot(ectionrequest:50hrs.Reportedlessonslearnedaroincorporatedintothelicensingprocessandfodbacktoindustry.FonvardcommentsregardingburdenesUmatotothoRecordsManagementBranch(TWF33).U.S.Nuc(oarRegulatoryCommission,Washington,DC20555000(,andtothoPapetwotkReductionProject(315(40104),OfrcoofManagementandBudget,Washington,DC20503.IfaninformationcoBectiondoesnctdisplayacurrentlyvalidOMBcontrolnumber.theNRCmaynctconductorsponsor.andaFACILITYNAME(1)R.E.GinnaNuclearPowerPlant00CKETNUMBER(2I05000244PAGE(3)1OF5TITLEte)SurveillanceNotPerformed,DuetoPersonnelError,ResultedinViolationofTechnicalSpecificationsEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIESINVOLVED(8)MONTHOAYYEARYEARSEQUENTIALNUMBERREVISIONNUMB(RMONTHOAYYEARFACILITYNAMEDOCKETNUMBER050000227OPERATINGMODE(9)POWERLEVEL(10)1999701999-002-0003291999FACILITYNAMEDOCKETNUMBER0500020.2201(b)20.2203(a)(1)20.2203(a)(2)(I)20.2203(a)(2)(v)20.2203(a)(3)(l)20.2203(a)(3)(n)50.73(a)(2)(l)50.73(a)(2)(II50.73(a)(2)(III50.73(a)(2)(vill)50.73(a)(2)(xl73.71URSUANTTOTHEREQUIREMENTSOF10CFREI(Checkonoormore)(11)THISREPORTISSUBMITTEDP20.2203(a)(2)(II)20.2203(a)(2)(Ill)20.2203(a)(2)(lv)20.2203(a)(4)50.36(c)(1)50.36(c)(2)LICENSEECONTACTFORTHISLER(12)50.73(a)(2)((v50.73(a)(2)(v50.73(a)(2)(vlOTHERSpecifyinAbstractbelowor(nNRCForm366ANAMETELEPHONENUMBERUscexfeAtesCode)JohnT.St.Martin-TechnicalAssistant(716)771-3641CAUSESYSTEMCOMPONENT'ANUFACTURERREPORTABLETOEPIXCAUSESYSTEMCOMPONENTMANUFACTURERREPORTABLETOEPIXSUPPLEMENTALREPORTEXPECTEDR4)YES(Ifyes,completeEXPECTEDSUBMISSIONDATE).XNOEXPECTEDSUBMISSIONDATE((5)MONTHOAYABSTRACT(Llmltto1400Spaces,I.e.,approximately15single-spacedtypewrittenHnos)(16)OnFebruary27,1999,atapproximately1600EST,theplantwasincoastdownpriortothe1999refuelingoutage,inMode1atapproximately70%steadystatereactorpower.Itwasdiscoveredthatasurveillancehadnotbeenperformedatthefrequencyrequiredbytheplant'sTechnicalSpecifications.Thisconstitutedamissedsurveillance,whichisaconditionprohibitedbytheplant'stechnicalspecifications.ControlRoomoperatorsverifiedthattheplantwascurrentlyincompliancewiththesesurveillancerequirements.Noimmediatecorrectiveactionwasneeded.Theunderlyingcauseofnotperformingthissurveillancewasapersonnelerror.CorrectiveactiontopreventrecurrenceisoutlinedinSectionV.B.

0NRCFORM366A(61996)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)DOCKET(2)LERNUMBER(6)yEARSEQUENTIALONREVISINUMBERNUMBEPAGE(3)R.E.GinnaNuclearPowerPlant050002441999002-002OF5TEXTillmorespaceisreouired,useadditionalcopiesolNRCForm366AI(171PRE-EVENTPLANTCONDITIONS:OnFebruary27,1999,atapproximately1600EST,theplantwasincoastdownpriortothe1999refuelingoutage,inMode1atapproximately70%steadystatereactorpower.OneoftheresponsibilitiesoftheControlRoomoperatorsistoperformthecomputerchecksinaccordancewithplantprocedureS-26.1(ComputerProgramCheck).ControlRoomoperatorshadjustcompletedthesecomputerchecks,tomeettheSurveillanceRequirements(SR)oftheGinnaStationImprovedTechnicalSpecifications(ITS).Step5.4ofplantprocedure0-6.13(DailySurveillanceLog)requiresthatthecomputerprogramchecksbeperformedevery8hours.II.DESCRIPTIONOFEVENT:A.DATESANDAPPROXIMATETIMES,OFMAJOROCCURRENCESoFebruary26,1999,2318EST:SR3.2.3.1isperformed.oFebruary27,1999,0728EST:ItwasintendedthatSR3.2.3.1beperformed.oFebruary27,1999,1418EST:Eventdateandtime.oFebruary27,1999,1539EST:SR3.2.3.1isperformed.oFebruary27,1999,1600EST:Discoverydateandtime.oFebruary27,1999,2326EST:SR3.2.3.1isperformed.EVENT:OnFebruary27,1999,atapproximately1600EST,theplantwasincoastdownpriortothe1999refuelingoutage,inMode1atapproximately70%steadystatereactorpower.ControlRoomoperatorshadjustcompletedcomputerchecks,tomeettheSRoftheITS.Specifically,SR3.2.3.1,whichverifiesoperabilityoftheAxialFluxDifference(AFD)monitor,hadbeenperformedatapproximately1539EST.PerformanceofthisSRisrequiredataFrequencyof12hours,perITSSR3.2.3.1.GinnaStationadministrativerequirements,aslistedinOperationsProcedure0-6.13,"DailySurveillanceLog",aretoperformthisSRonceduringeveryeighthourtimeblock.OneoftheoperatorsmentallyquestionedwhetherhehadactuallyperformedSR3.2.3.1whenhehadpreviouslyperformedthesecomputerchecksatapproximately0728EST.NotethatproperperformanceofSR3.2.3.1resultsinthereceiptofseveralalarmswhicharereceivedonthePlantProcessComputerSystem(PPCS)anddocumentedonthePPCSalarmprintout.TheControlRoomoperatorconductedadditionalself-checking.Herealizedhiserrorduringthesecondcheckofthedaywhen,usingtheprocedure,hecouldnotrecallperformingstep5.4ofprocedureS-26.1.HeimmediatelyinformedtheControlRoomForemanaboutthepotentialmissedsurveillance.AfteracheckofthePPCSalarmprintout,boththeForemanandtheControlRoomOperatorrealizedthatthesurveillancehad,infact,beenmissed.TheydiscoveredthattherehadbeennoPPCSalarmsgeneratedaroundthetimeframeof0738EST,andconcludedthatSR3.2.3.1hadnotbeenperformedat0728EST.ReviewofthePPCSalarmprintoutconfirmedthatSR3.2.3.1hadbeenperformedatapproximately2318ESTonFebruary26,1999.

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NRCFORM366A(6.1998)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKET(2)05000244LERNUMBER(6)SEQUENTIALREVISINUMBERNUMBE1999-002-00PAGEI3)3OF5TEXTfffmorespeceisrerfuired,useedditionelcopiesofNRCForm366Af)171InaccordancewithITSSR3.2.3.1,thisSRwasduewithin12hours.Applyingtheapplicabilityrequirements'ofITSSR3.0.2,thespecificFrequencyismetifthesurveillanceisperformedwithin1.25timestheintervalspecified(1.25times12resultsin15hours).Thus,thelatestSR3.2.3.1couldbeperformedwouldhavebeen15hoursafter2318hours,orapproximately1418ESTonFebruary27,1999.Time1418onFebruary27istheEventdateandtime.AlthoughSR3.2.3.1hadbeenmissedat0728EST,theAFDmonitorcontinuedtobefullyfunctional.ReviewofPPCSalarmsconfirmedthatSR3.2.3.1hadbeenproperlyperformedatallothertimesinFebruary1999,atthefrequencyrequiredbytheplant'sTechnicalSpecificationsandprocedure0-6.13.C.INOPERABLESTRUCTURES,COMPONENTS,ORSYSTEMSTHATCONTRIBUTEDTOTHEEVENT:NoneD.OTHERSYSTEMSORSECONDARYFUNCTIONSAFFECTED:NoneE.METHODOFDISCOVERY:Thiseventwasindicatedduringmentalquestioningofprevious.actions,andwasformallydiscoveredbyreviewofPPCSalarmprintouts.F.OPERATORACTION:TheControlRoomoperatorsidentifiedthatSR3.2.3.1hadinadvertentlynotbeenperformedatapproximately0728ESTonFebruary27.Atthetimeofdiscovery(1600EST),ControlRoomoperatorsverifiedthattheplantwascurrentlyincompliancewiththesesurveillancerequirementsandthattheAFDmonitorwas,andhadbeen,operable.Noimmediatecorrectiveactionwasneeded.G.SAFETYSYSTEMRESPONSES:NoneIII.CAUSEOFEVENT:A.IMMEDIATECAUSE:TheimmediatecauseoftheconditionprohibitedbyTechnicalSpecificationswasamissedsurveillanceinthatSR3.2.3.1wasnotperformedwithin15hoursafter2318ESTonFebruary26.

rt ONRCFORM366A(6.1999)LICENSEEEVENTREPORT(LERJTEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclearPowerPlantOOCKET(2)05000244LERNUMBER(6)YEARSEQUENTIALONREVISINUMBERNUMBE1999-002-00PAGE(3)4OF5TEXTfilmorespecoisrecurred,usoeddidonelcopiesofNRCForm366AJ1171B.INTERMEDIATECAUSE:TheintermediatecauseofthemissedsurveillancewasinadvertentlynotperformingSR3.2.3.1atapproximately0728ESTonFebruary27.ROOTCAUSE:TheunderlyingcauseofthemissedsurveillancewasapersonnelerrorbyanRG(tIElicensedoperator,whoperformedseveralseparatetasksassociatedwithsomeroutineITSSRsthatareperformedusingthePPCS,andinadvertentlydidnotperformITSSR3.2:3.1atthattime.ThiserrorwasacognitiveerrorinthatthelicensedoperatordidnotrecognizeordetectthathehadfailedtoperformSR3.2.3.1at0728EST.InadvertentlynotperformingSR3.2.3.1wascontrarytoapprovedprocedures,inthattheprocedurerequiredtheSRbeperformedeveryeighthours.TherewerenounusualcharacteristicsintheControlRoomthatdirectlycontributedtotheerror.IV.ANALYSISOFEVENT:Thiseventisreportableinaccordancewith10CFR50.73,LicenseeEventReportSystem,item(a)(2)(i)(B),whichrequiresareportof,"Anyoperationorconditionprohibitedbytheplant'sTechnicalSpecifications".Themissedsurveillanceisaconditionprohibitedbytheplant'stechncialspecifications.Anassessmentwasperformedconsideringboththesafetyconsequencesandimplicationsofthiseventwiththefollowingresultsandconclusions:Therewerenooperationalorsafetyconsequencesorimplicationsattributedtothemissedsurveillancebecause:TheAFDisameasureofaxialpowerdistributionskewingtothetoporbottomhalfofthecore.TheAFDis.definedasthedifferenceinnormalizedfluxsignalsbetweenthetopandbottomhalvesofatwosectionexcoreneutrondetectorineachdetectorwell.Forconvenience,thisfluxdifferenceisconvertedtoprovidefluxdifferenceunits.TheallowedrangeoftheAFDisusedinthenucleardesignprocesstohelpensurethatcorepeakingfactorsandaxialpowerdistributionsmeetsafetyanalysisrequirements.SR3.2.3.1istheverificationthattheAFDmonitorisoperable.ThisisnormallyaccomplishedbyiritroducingasignalintothePPCStoverifycontrolroomannunciationofAFDnotwithinthetargetband.TheFrequencyof12hoursissufficienttoensureoperabilityoftheAFDmonitor,sinceundernormalplantoperationtheAFDisnotexpectedtosignificantlychange.SR3.2.3.1hadbeenproperlyperformedatalltimespriortothisevent,andwasproperlyperformedatapproximately1539ESTand2326ESTonFebruary27,confirmingthattheAFDmonitorwasoperable.ThefrequencyofmonitoringtheAFDbythePPCSisnominallyonceperminute.Thismonitoringcontinuedthroughoutthisevent.

NRCFORM366A1619)8)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSION~FACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKETI2)05000244LERNUMBERI6)YEARSEOUENTIALONREVISINUMBERNUMBE1999-002-00PAGEI3)5OF5TEXTillmorespeceisrequired,useeddaionelcopiesolltiRCFormJ66AI117)oWiththermalpower(90%ofreactorthermalpower(RTP),theAFDmaybeoutsidethetarget'bandprovidedthatthedeviationtimeisrestricted.ItisintendedthattheplantisoperatedwiththeAFDwithinthetargetbandaboutthetargetfluxdifference.oInoperabilityofthealarmdoesnotnecessarilypreventtheactualAFDvaluesfrombeingavailable(e.g.,fromthecomputerlogsorhandlogs).AFDvaluesforthepreceding24hourscanbeobtainedfromthehourlyPPCSprintoutsorhandlogs.IftheAFDmonitorhadbeeninoperableduringoperationat(90%RTP,theAFDmeasurementismonitoredataSurveillanceFrequencyof1hourtoensurethattheAFDiswithinitslimits.Basedontheabove,itcanbeconcludedthattherewerenounreviewedsafetyquestions,andthatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVEACTION:A.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENTNORMALSTATUS:SincetheAFDmonitorwasoperableatthetimeofdiscovery,noimmediatecorrectiveactionswereneeded.B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:oProcedure0-6.13willbeevaluatedfortheenhancementofdocumentationofthecompletionofITSSRs.oLessonslearnedfromthiseventwerediscussedwiththelicensedoperatorwhoinadvertentlydidnotperformSR3.2.3.1.Emphasiswasplacedonattentiontodetail.oOperationssupervisionwillreviewthisLERandcorrectiveactionswithalloperatingshifts.VI.ADDITIONALINFORMATION:A.FAILEDCOMPONENTS:NoneB.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistoricalsearchwasconductedwiththefollowingresults:NodocumentationofsimilarLEReventswiththesamerootcauseatGinnaStationcouldbeidentified.C.SPECIALCOMMENTS:None