ML17261A450

LER 87-002-00:on 870306,RCS Oxygen Analysis Indicated That Steady State Requirements of Tech Spec 3.1.6.2 Had Been Exceeded.Caused by Personnel Error & Procedural Inadequacy. Procedural Guidance Being developed.W/870405 Ltr

ML17261A450
Person / Time
Site:	Ginna
Issue date:	04/05/1987
From:	FILKINS D L, KOBER R W ROCHESTER GAS & ELECTRIC CORP.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-87-002, LER-87-2, NUDOCS 8704130520
Download: ML17261A450 (9)

Text

REGULATORYFORMATIONDISTRIBUTIONSYM(RIDS)ACCESSIONNBR:8704130520DOC.DATE:87/04/05NOTARIZED:NOFACIL:50-244RobertEmmetQinnaNuclearPlant>Unit1>RochesterGAUTH.NAMEAUTHORAFFILIATIONFILKINSsD.L.-RochesterQas5ElectricCorp.KOBERiR.W.RochesterGasScElectricCorp.RECIP.NAME.RECIPIENTAFFILIATIONDOCKET005000244

SUBJECT:

LER87-002-00:on87030&iRCSoxygenanalysisindicatedth"tsteadystaterequirementsowTechSpec3.i.h.2hadbeenexceeded.CausedbypersonnelerrorZcproceduralinadequacy.Proceduralguidancebeingdeveloped.W/870405ltr.DISTRIBUTIONCODE:IE22DCOPIESRECEIVED:LTRENCLSIZE:TITLE:50.73LicenseeEventReport(LER)iIncidentRpt>etc.NOTES:LicenseExpdateinaccordancewith10CFR2>2.109<9/19/72).05000244RECIPIENTIDCODE/NAMEPD1-3LASTAHLEiCINTERNAL:ACRSMICHELSONACRSNYLIEAEOD/DSP/ROABNRR/ADTNRR/DEST/ADSNRR/DEST/ELBNRR/DEST/MEBNRR/DEBT/PSBNRR/DEST/SQBNRR/DLPG/GABNRR/DREP/EPBi/PMASRBEQ02RQN1FILE01EXTERNAL:EQRQQROH>MLPDRNSICHARRISJCOPIESLTTRENCL1111112211101111111111111111551111RECIPIENTIDCODE/NAMEPD1-3PDACRSMOELLERAEOD/DOAAEOD/DSP/TAPBNRR/DEST/ADENRR/DEST/CEBNRR/DEST/ICSBNRR/DEST/MTBNRR/DEST/RSBNRR/DLPG/HFBNRR/DOEA/EABNRR/DREP/RABNRR/PMAS/PTSBRESSPEISiTHSTLOBBYNARDNRCPDRNSICMAYSiGCOPIESLTTRENCL1'111111011111-11111111111111TOTALNUMBEROFCOPIESREQUIRED:LTTR41ENCL39 HrICForm$OO10421LICENSEEEVENTREPORTILERIU.S.NUCLEARREOVLATORYCOMMISSIONAFFROUEOOMSHO.$190W10aKXFIRKS:Sn)ISSFACILITYNAME(Il'.E.GinnaNuclearPowerPlantoocxtTIavMsthl21osoo,o244>o(:07RtFORTOATS(1)LthHUMSKR(I)OOCXKTHVMSKRISIps000EVENTOATSIS)MONTHOAYYEARFACII,ITVH*MOSOTHERFACILIT)ttIHVOLYEO(SIYEARrravraaarrrrvMo~ROAYaa0varraIALy?gHVMOSRMONTHYEARReactorCoolantSystemOxygenConcentrationExceedsTechnical'pecificationLimitsDue-ToPersonnelErrorandProceduralInadea'.;.0306878700200040587O500()OFSRATIHOMOOS(Sl~OIYKRppp110120.402(SI20.OCS(a)(11(020a004)(ll(tl20.409(al(litt)I20A004)ill~()el20.400(al(Illa)20.a00(alSOM(al(I)90.$9(~)(2)90.2$4)al(0SO.T$41121(~I90.22(a)12)(SOLICENSEtCONTACTFORTHISLthlit)SO,2$4I(2)IIv)SO.2$4)(2)(el90.2241(21(et)SO.T$4)121(aOI)IAI90.2$(~I(21(rat)(S)90.2$la)12)(a)THISREFORTISSUSMITTEOFURSUANTTOTHEREOUlhtlatNTSOF10CFR$r(CooersorrorNmorooIraraIotorerrrgl(11TS.TIW2$.7((a)OTHKRItooaloyMAoroeataaronarroIoI'aat,NhcFomr$SMINAMErDuaneL.Filkins,Manager,HealthPhysicsandChemistryTELKFHOHKNUMSERAREACOOK315524-4446COMFLSTSONKLINKI'OREACHCOMFOHKNTFAILUREOtSCRISKOIHTHISRtFORTl12)CAUSESYS'EMCOMFOHKNTMANUFACTUNEREFORTASLETONFROSR~%A'FCAVSESYSTEMCOMFONENTMAHVFAGTUNERKFORTASLTOHOROS%VISUFFLKMKNTALRtFORTtXFKCTtOI)alYESIllFar,oomo)eriEXPECTEDSVSMI$$IONOATETHOAKKTRAcT(LamiaIof400a)racer.l.o.ooororarrateryhtrearrarroroeoeaoryarerrrrnNrlkroal(19)EXFECT'EOSUSMISSIONOATSIISIMONTHOAYYEAR.DuringstartupfromarefuelingoutageonMarch6,1987,at0009EST,areactorcoolantsystem(RCS)oxygenanalysisindicatedthatt:hesteadystaterequirementsofTechnicalSpecification(TS)3.1.6.2hadbeenexceeded.Areviewofthepreviousdaysanalyticalresultsindicateda-previousanalysisonMarch5,1987,hadindicatedasimilarresultwhichviolatedthe24hourlimitingconditionforoperationinTS3.1.6.4.Areactorcoolantsystemcooldownwasinitiatedtoloversystemtemperatureandtoallowadditionofhydrazinetoscavengeoxygenfromthesystem.ThecauseforexceedingtheTSrequirementswaspersonnelerrorandproceduralinadequacy.TherewasnoproceduralguidanceintheoperatingprocedureswhichcorrelatesrequiredchemistrysamplingtoRCStempera-ture.ThetechniciandidnotinitiallyrecognizethatTSrequirementshadbeenexceeded.ToprecluderecurrencebetterproceduralguidanceisbeingdevelopedandtechniciantrainingwillbeperformedbasedonthisLER.Therewerenosignificantsafetyconsequencesofthisincident.87041305205000244087040>PgRAgoC'KpgRS~HRC'Fern$90~~*~.c~(9021wi NACPererSSSA(9891LICENSEEEVENTREPORT(LERITEXTCONTINUATIONU.S,NUCLEAAAEOULATOAYCOMMISSIONAPPROVEOOMSNO.SISOW(04EX~INES:8(SI(85I'ACILITYNAME(llR.E.GinnaNuclearPowerPlantTEXT(IfrrrereNreceIrreeeeee,wecere(lre(Hr(CferrrrJSSAYl(IllOOCXETNUMSEI((SIosooo244LEIINUMEEI(ISIYEAN.p)8SSOUSNTIALPrÃeeyrSIONNUMTrlrerrrUMee7-002-0~AOE(SI2oF07I.PRE-EVENTPLANTCONDITIONSOnMarch4,1987,theunitwasstartingupfromtheannualrefuelingandmaintenanceoutage.Onthisdatetheplantleftthecoldshutdownconditionandheateduptoapproximately315F,350psigreactorcoolantsystem(RCS)temperatureandpressure,respectively,toperformsteamgenerator(S/G)crevicecleaningperoperatingprocedure.0-10.TheTSrequirementsforRCSoxygenoflessthan0.1ppmhadbeenachievedpriortoincreasingRCStemperatureabove200oF.II.DESCRIPTIONOFEVENTA.EVENTOnMarch6,1987,at0009ESTwithS/Gcrevicecleaninginprogress,aRCSsamplewastakenasrequiredbyAttachmentIofprocedurePC-1.1(PrimarySystemAnalysisScheduleandLimits).ThisprocedureoutlinestherequiredanalysisandlimitsforRCSchemistryduringhotshutdownandnormaloperation.Theresultoftheoxygenanalysisoftheabovesamplewas0.5ppm.Theplanttechnicianperformingtheanalysisrecognizedthisresulta6anumbergreaterthanallowedbyTSfortheexistingplantconditions.Asisroutine,aconfirmingsamplewastakenandanoxygenanalysisperformedat0130ESTwiththesameresult.AreviewoftheplanttechnicianslaboratorynotebookrevealedthatonMarch5,1987at0030EST,anothersampleandanalysishadbeenperformedwhichalsoindicatedoxygenconcentrationintheRCSgreaterthan0.1ppm.TheGinnaStationTS,Section3.1.6.2,requiresthatcorrectiveactionbetakenimmediatelywhenthenormalsteadystateRCSoxygenconcentrationlimitof0.1ppmisexceeded.AlsoTSSection3.1.6.4requiresthatifthenormalsteadystatelimitsforRCSoxygenareexceeded-andcannotbereturnedtowithinthelimitswithin24hours,thereactorshallbebroughttothecoldshutdowncondition.Because,from0030ESTonMarch5,1987,until0235ESTonMarch6,1987,(alapsedtimeofapproximately26hours),theRCSoxygenconcen-trationexceededitsnormalsteadystatelimitwithnocorrectiveactiontaken,bothsectionsofTS,3.1.6.2and3.1.6.4wereexceeded.B.INOPERABLESTRUCTURES,COMPONENTSORSYSTEMSTHATCONTRIBUTEDTOTHEEVENT:Nonerr(981I NRCFmwJTSAl9SJILICENSEEEVENTREPORT(LER)TEXTCONTINUATIONV.S.NVCLKARRSOVLATORYCOMMISSIONAPPROY500MSNO,JI50&IdiSXPIRTSS/JI/95FACILITYNAMSIllR.E.GinnaNuclearPowerPlant:TTJTIITraceepoCPIIleeAwd.Pae~NIICfOneJTSAJI0T)OOCKKTNVMJSRIJIooooo44LTRNVMJSRISIYSAR~X,STCUTNTIAL:NATY>SUNNMTTR.'i~FNUMTR870020~AOIIJI03ap07C.DATESANDAPPROXIMATETIMESFORMAJOROCCURRENCES:-oMarch4,1987,0900EST:Unitleavescoldshutdown,RCS.oxygenconcentrationlessthan0.1ppm.oMarch5,1987,0030EST:Eventdate.oMarch6,1987,0009EST:Discoverydate.oMarch6,1987,0130EST:Confirmatory.sampletaken.oMarch6,1987,0235EST:Plantcooldowninitiated.NoMarch6,1987,0800EST:RCSaveragetemperaturelessthan250oF.oMarch6,1987,1030EST:RCSoxygenconcentrationwithinTSrequirements.D.OTHERSYSTEMSORSECONDARYFUNCTIONSAFFECTED:NoneE.METHODOFDISCOVERY:Theeventwasmadeapparentduringtheforeman'sreviewoftheplanttechnicianslaboratorynotebook.F.OPERATORACTION:TheplanttechnicianreportedtheeventtotheControlRoom.TheControlRoomoperatorsinitiatedaplantcooldownperTSrequirementsat0235ESTonMarch6,1987.By0800ESTtheRCSaveragetemperaturewaslessthan250F.At0935ahydrazineadditionwasmadetotheRCSwhichbroughttheoxygenconcentrationwithinTSrequirementsby1030EST.SAFETYSYSTEMRESPONSES:Nonek'f7DlAelll95JI NRCSarraSSSA(985)LICENSEEEVENTREPORTILER)TEXTCONTINUATIONU.S.NUCLEARREOULAIORYCOMMISSIONAP/rROVEOOMSNO.5150&l0eEXelRES.8/Sl/85aACILITYNAME(IIR.E.GinnaNuclearPowerPlantTEXT///mareeaece/e/rr/rerLeeee~AlRC/rarm8(/SA'e/IITIIII.CAUSEOpEVENTOOCKETNUMSER(llosooo244LERNUMSER(SISEQUENT/*Ll),)IYIS0Nvv8I~~r/UMSKA70200eACE(sI04pFO7A.IMMEDIATECAUSE:RCSoxygenconcentrationwasgreaterthanthenormalsteadystateTSlimitformorethan24hourswithnoimmediatecorrectiveactiontaken.ThiswasduepartiallytoacognitiveerrorsincethetechnicianfailedtorecognizethattheanalyticalresultsexceededtheTSrequirementsfortheRCStemperaturewhichexistedatthetime.ItwasalsopartiallytheresultofaproceduralinadequacysincetherewasnoproceduralguidanceintheoperatingprocedurewhichcorrelatedrequiredchemistrysamplingtoRCStemperature.B.ROOTCAUSE:Theresultsofarootcauseinvestigationdeterminedthatthereweretwomajor.rootcausesthatcontributedtotheevent.Theseareasfollows:TheHealthPhysicsandChemistrysectionfailedtorecognizetheRCSoxygenconcentrationwasexceedingTSrequirementsforapproximately24hours.Thisoccurredbecauseofthefollowingreasonsandactions:oThecrevicecleaningoperatingprocedureholdstheRCStemperaturebetweencoldshutdownandhotshutdownforextendedperiodsoftime.0Theplantchemistryprocedure,PC-1.1,onlyprovidedascheduleforanalysisforthefollowingplantconditions:0a.Hotshutdownornormaloperation,AttachmentIb.Coldshutdown,AttachmentIIc.Refuelingshutdown,AttachmentIIIOnMarch5,1987,AttachmentIIwasinuse,whichdidnotrequireaRCSoxygenanalysisbetaken.ThetechnicianwhoperformedtheoxygenanalysisonthisdatehadreceivedaverbalrequestfromanothertechniciantoruntheRCSoxygenanalysiswithnoapparentreasongiven.Sincetheanalysiswasnotrequired,hedidnot,recognizethesignificanceoftheresults.NRCeORM888*t985I NRClorna844AI98SILICENSEEEVENTREPORTILER)TEXTCONTINUATIONV.S.NUCLEARREOULATORYCOMMISSIONATPROYEOOM8NO.SISOMI04EXPIRES:8ISII8$tACILITYNAMEIIIR.E.GinnaNuclearPowerPlantOOCKETNUMEERISILERNUMEERl4lYEAR,'8@slQUENTIALgPntvataonNUMttll..rNUMttnTACEISITEXTlitmoroNaoco*rotarooe'.ooooOtrnrnaMHRCrranrn848A'rIIITIosooo2487,0020'0'5QF07.0TheanalyticalresultsforRCSchemistryarenormally.enteredintothePrimarySystemChemistryLogandalsoontheDailyChemistryAnalysisResultsFormwhichisforwardedtoOperationsdaily.ThechemistryresultsobtainedonMarch5,1987,werenotenteredoneitheroftheserecords.SupervisoryreviewLofthechemistrylogdidnotrecognizethelackofresultsforMarch.5,1987,untilMarch6,1987,andOperationsalsodidnotrecognizethelackofresultsforMarch5,1987.AlthoughthereviewoftheselogswouldnothaveprecludedexceedingtherequiremegtsofTS3.1.6.2,itislikelythatcorrectiveactionwouldhayebeentakenpriortoexceeding24hoursiftheresultshadbeenproperlylogged.2.TheunanticipatedoxygenconcentrationincreaseintheRCS.Thishappenedbecauseofthefollowingreasonsandactions:oTheinvestigationofthecauseoftheoxygenincreaseintheRCSrevealedthatthestep.inprocedure0-10whichrequiresburpingofthevolumecontroltank(VCT)withhydrogenhadbeenmarkednon-applicable'(N/A);Thisisallowed-procedurally.andOperationshadbeendirectedbytheoutageplanninggrouptoproceedwithonlyanitrogenoverpressureontheVCT.Thishadbeendoneinthe1985and1986outageswithoutoxygenexcursions,sothiswasnotwithoutprecedent.Thereasonfornotintroducinghydrogenistoallowamorerapidturnaroundifsystemleaksshoulddevelopduringperformanceoftheprimarysystemhydro.IfthehydrogenconcentrationisincreasedintheRCS,operatingproceduresrequireremovalpriortosystemdraindowntoprecludepossibleexplosivemixturesinprimarycomponents.Thisisatimeconsumingprocess.0Withouthydrogentocontroloxygen,anysourceofoxygenwouldcauseincreasesintheRCSoxygenconcentration.ThreesourcesthatcouldhavecontributedtotheoxygeningresstotheRCSwere:a.ThevolumecontroltankwasnotburpedsoanyoxygeninthetankwouldhavebeenallowedtocomeintoequilibriumwiththeRCS.aa'aI98SI NRCiona$48A19881LICENSEEEVENTREPORT{LER)TEXTCONTINUATIONV.S,NUCLEARREOVLATORYCOMMISSIONAPPROVEDOMENO.S($0&(08EXPIRES:8/SI/8$PACILIEYNAMElllR.E.GinnaNuclearPowerPlantDOCKET'VMEER(EILERNVMEER(81YEAR@'80vENT/AL$8)aov/SionNUMPEN~aNVMoaSEXY///naaoNN(o/o~,oooo////oao/HRCAN/a80848I(11(osooo2448700006ov0'7b.c~Normalintroductionofreactormake-upwaterwouldintroduceoxygenintotheRCS.Someoxygenwouldhavebeenformedbyradiolysisofwaterwhilepassingthroughthecore.IV.ANYSISOFEVENTIThiheventisreportableinaccordancewith10CFR50.73,LicenseeEventReportSystem,Item(a)(2)(i)(B),whichrequiresreportingof"anyoperationprohibitedbytheplant'sTechnicalSpecifi-cations>>inthattheplantwasinadegradedmodeavowed'bytheTechnicalSpecificationsforaperiodoftimelongerthanthatpermittedbytheTechnicalSpecifications.Anassessmentwasperformedofthesafetyconsequencesandimpli-cationsoftheeventwiththefollowingresultsandconclusions:oThebasisforcontrolofoxygenintheRCSistominimizegeneralcorrosionandtopreventlocalizedstresscorrosioninthepresenceofchlorideandfluorideions.Duringtheperiodoftimethattheoxygenconcentrationwasoutsidetheoperatingband,.boththechlorideandfluorideconcentrationswerewellbelowthenormaloperatingrequirements.oSincetheoxygenconcentrationsneverexceededtheTStransientlimits(always0.5ppmorless)andthechlorideandfluorideconcentrationswerewithinrequirements,therewouldhavebeennoanticipateddegradationofRCSsystemcomponentsand,therefore,nosafetyconsequencesorimplicationsfromthisevent.V.CORRECTIVEACTIONA.ACTIONSTAKENTORETURNTHERCSOXYGENCONCENTRATIONTONORMALSTEADYSTATEOPERATINGVALUES:oTheRCSwascooleddowntolessthan250oFtoallowtheadditionofhydrazinetoscavengetheoxygen.oHydrazine'asaddedtotheRCSandoxygenwasbroughtwithinTSlimits.B.ACTIONSTAKENORPLANNEDTOPREVENTRECURRENCE:nlRaila(84$10CorrectiveactioncurrentlyinprogresswillprovidebetterproceduralguidancetoassuretheHealthPhysicsandChemistrysectionisawarewhentheRCStemperature-hasbeenincreasedandchemistryrequirementshavechanged.

NIICPena588A19831LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLTAIIIITOULATOIIYCOMMISSIONAPPAOY8OOM8NO.31$0WI058XPIA85"8ITI/8$PACILITYNAM8lllR.E.GinnaNuclearPowerPlant-OOCK8TNUM88IILTILKIINUM88II181YTAAj>pI55QUCNTIAL&Aileayl5%n,c,.?NUM8P4'UMTePA48151TtxTIII<<eeaapacela>>aakaf,a>>aaAveavlryilcPane888A81Illlosooo24487-002-007DF07oTheHealthPhysicsandChemistrytechniciansinvolvedwithprimarysystemchemistryhaveallbeenmadeawareoftheerrorswhichcontributedtotheevent.oAcopyofthisLERwillbeforwardedtotheTrainingsectionandwillbe.includedinthetrainingprogramfortheHealthPhysicsandChemistrysection.VI.ADDITIONALINFORMATIONA.FAILEDCOMPONENTS:Therewerenocomponentfailuresthatcontribgtedtothisevent.B.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistoricalsearchwasconductedwiththefoilowingresults:nodocumentationofsimilarLEReventscouldbeidentified.Nc019851

.=?Cl"HEIE"arl~,r55r57aN.OE,'87,<Veau@Ronl~B>w,Av.>va~g-oco>a'C.5April5,1987U.S.NuclearRegulatoryCommissionDocumentControlDeskWashington,DC30555

Subject:

LER87-002,ReactorCoolantSystemOxygenConcentrationExceedsTechnicalSpecificationLimitsDuetoPersonnelErrorandProceduralInadequacyR.E.GinnaNuclearPowerPlantDocketNo.50-244Inaccordancewith10CFR50.73,LicenseeEventReportSystem/Item(a)(2)(i)(B)whichrequiresareportof"anyoperationprohibitedbytheplantTechnicalSpecifications",theattachedLicenseeEventReportLER87-002isherebysubmitted.~~Vtrulyyours,xc:U.S.NuclearRegulatoryCommissionRegionI631ParkAvenueKingofPrussia,PA19406GinnaUSNRCResidentInspectorRogerW.Kober