ML17332A547

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LER 94-014-00:on 941225,discovered That TS Surveillance 4.11.2.1.2 Gland Seal Exhaust Weekly Gaseous Effluent Grab Sample Not Completed for 941217-25.Caused by Personnel Error.Surveillance Schedule Sheet modified.W/950124 Ltr
ML17332A547
Person / Time
Site: Cook American Electric Power icon.png
Issue date: 01/24/1995
From: BLIND A A, MOREY D O
INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-94-014, LER-94-14, NUDOCS 9502020100
Download: ML17332A547 (6)


Text

RIDRITY(ACCELERATEDRIDSPROCI'.SSliGiREGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ACCESSIONNBR:9502020100DOC-DATE:95/01/24NOTARIZED-NODOCKET.NFACIL:50-315DonaldC.CookNuclearPowerPlant,Unit1,IndianaM05000315AUTH.NAMEAUTHORAFFILIATIONMOREY,D.O.IndianaMichiganPowerCo.(formerlyIndiana&MichiganEleBLIND,A.A.IndianaMichiganPowerCo.(formerlyIndiana&MichiganEleRECIP.NAMERECIPIENTAFFILIATION

SUBJECT:

LER94-014-00:on941225,discoveredthatTSsurveillance4.11.2.1.2glandsealexhaustweeklygaseouseffluentgrabsamplenotcompletedfor941217-25.Causedbypersonnelerror.Surveillanceschedulesheetmodified.W/950124ltr.DISTRIBUTIONCODE:IE22TCOPIESRECEIVED:LTRgENCLiSIZE:TITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.NOTESRECIPIENTIDCODE/NAMEPD3-1PDINTERNAL:AEOD/SPDjRABF/IZCENTE@02NRR/DE/EELBNRR/DISP/PIPBNRR/DRCH/HHFBNRR/DRCH/HOLBNRR/DSSA/SPLBRES/DSIR/EIBEXTERNAL:LSTLOBBYWARDNOACMURPHY,G.ANRCPDRCOPIESLTTRENCL111111111111111111111111RECIPIENTIDCODE/NAMEHICKMAN,JAEOD/SPD/RRABNRR/DE/ECGBNRR/DE/EMEBNRR/DOPS/OECBNRR/DRCH/HICBNRR/DRSS/PRPBNRR/DSSA/SRXBRGN3FILE01LITCOBRYCEPJHNOACPOORE,W.NUDOCSFULLTXTCOPIESLTTRENCL111111111111221111221111i'OTETOALL"RlDS"RECIPIENTS:PLEASEHELPl'STOREDL'CEiVASTE.'OiIAC'I"IHEDOCL'iIEiTCONTROLDESk.ROOXIPl-3"(EXT.5%.2083)TOILlilli:KTEi'OI.'lI%ANILPROilDISTRIDl'TIOiLISTSI:ORDOCI.'illX'I'SYol.')Oi'"IiI.:I:.D'ULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR26ENCL26

IndianaMichiganPowerCompanyCookNuclearPlant~OneCookPlaceBridgman,Ml491066164655901INDIANANICHIGANPOWERJanuary24,1994UnitedStatesNuclearRegulatoryCommissionDocumentControlDeskRockville,Maryland20852OperatingLicensesDPR-58DocketNo.50-315DocumentControlManager:Inaccordancewiththecriteriaestablishedby10CFR50.73entitlediceseeEveteortSstemthefollowingreportisbeingsubmitted:94-014-00Sincerely,A.A.BlindPlantManager/sbAttachmentcJ.B.Martin,RegionIIIE.E.FitzpatrickP.A.BarrettR.F.KroegerM.A.Bailey-Ft.WayneNRCResidentInspectorJ.B.Hickman-NRCJ.R.PadgettG.Charnoff,Esq.D.HahnINPOS.J.Brewer9502020100950i24PDRADOCK050003i5SPDR NRCFORM366(5921.NUCLEARREGULATORYCOMMISSIONtAPPROVEDBYOMBNO.315~104EXPIRES5/31/95LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/charactersforeachblock)ESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISINFORMATIONCOLLECTIONREOUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHEtNFORMATIONANDRECORDSMANAGEMENTBRANCHIMNBBTTI4)~U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC205550001~ANDTOTHEPAPERWORKREDUCTIONPRCUECT(31500104),OFRCEOFMANAGEMENTANDBUDGET.WASHlNGTON,OC20503.FACILITYNAME(I)CookNuclearPlant-Unit1DOCKETNUMBER(2)osoooPAOE(3}10F3TITLE(4)WeeklyGaseousGrabSampleNotTakenDuetoPersonnelErrorEVENTDATE5LERNUMBER6REPORTNUMBER7OTHERFACILITIESINVOLVED8MONTH12DAYYEAR2594SEOUENTIALNUMBER94-O14REvlsroNNUMBER00MONTHDAY012495FACIUTYNAMECookUnit2FACIUTYNAMEDOCKETNUMBER05000316DOCKETNUMBER05000OPERATINGMODE(9)20.402(b)20.405(c)50.73(a)(2)(iv)73.71(b)THISREPORTISSUBMITTEDPURSUANTTOTHEREQUIREMENTSOF10CFR5:Checkoneormore11POWERLEVEL(10)10020.405(a)(1)(i)Fa20.405(a)(l](lt)20.405(a)(1)(lii)20.405(a)(1)(iv)20.405(a)(1)(v)50.36(c)(1)50.36(c)(2)ZS0.73(a)(2)(l)50.73(a)(2)(ii)50.73(a)(2)(iii)50.73(a)(2)(v)50.73(a)(2)(vii)50.73(a)(2)(viii)(A)50.73(a)(2)(viii)(8)50.73(a)(2)(lt)73.71(c)OTHER(SpeotyInAbstractbelowandInTexLNRCForm366A)LICENSEECONTACTFORTHISLER12NAMED.0.Morey,ChemistrySuperintendentTELEPHONENUMBER(IncludeAreaCode)616/465-5901X2502COMPLETEONELINEFOREACHCOMPONENTFAILUREDESCRIBEDINTHISREPORT13CAUSESYSTEMCOMPONENTMANUFACTURERREPORTABLETONPRDSCAUSESYSTEMCOMPONENTMANUFACTURERREPORTABLETONPRDSSUPPLEMENTALREPORTEXPECTED14YES(ttyes.completeEXPECTEDSUBMISSIONDATE)NoABSTRACT(Limitto1400spaces.i.e.,approximately15single-spacedtypewrittenlines)(16)EXPECTEDMONTHOAYYEARSUBMISSIONDATE(15)OnJanuary6,1995itwasdiscoveredthatTechnicalSpecificationsurveillance4.11.2.1.2forUnitsOneandTwoGlandSealExhaustweeklygaseouseffluentgrabsamplewasnotcompletedfortheperiodofDecember17throughDecember25,1994.Asthesamplingrequirementwasnotmet,thiseventisreportableunder10CFR50.73(a)(2)(i)(B),asaconditionprohibitedbyTechnicalSpecifications.TechnicalSpecification4.11.2.1.2requiresamonthlysurveillanceontheGlandSealExhaustforparticulate,iodineandtritiuminadditiontotheweeklygaseousgrabsample.TheindividualinvolvedmistakenlymarkedthelineitemforthegaseoussampleasnNotApplicable"(N/A)ontheNuclearTest,Schedulesystem,believingtheitemwasthemonthlysurveillanceforparticulate,iodineandtritiumwhichhadbeencompletedthepreviousweek.Thiseventisattributabletopersonnelerror.WeaknessesintheNuclearTestSchedulesystemscheduleformanditsusewereidentifiedduringtheinvestigation.Theseweaknesshavebeenaddressed.DuringthemonthofDecember1994,noabnormaloperationalactivitiesoccurredthatwouldhavecausedanalterationinthenormalnuclidecompositionofeitherunits'landSealExhausteffluent.Areviewofthegaseoussamplesobtainedbeforeandafterthiseventindicatednounusualnuclidespresent.Itwasconcludedthatthemissedsurveillancecreatednosafetyhazard,norwasthehealthandsafetyofthepublicjeopardizedatanytime.NRCFORM366r5921 NRCFORM355A(Ii(SSS)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONtAPPROVED0MBNO.3150010iEXPIRES,'i/30/02ESTIMATEDBURDENPKRRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:500HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENTBRANCH(F430),U.S.NUCLEARREGULATORYCOMMISSION.WASHINGTON.DC20555.ANDTOTHEPAPERWORKREDUCTIONPROJECT13150010il.OFFICKOFMANAGEMENTANDBUDGET,WASHINGTON,DC20503.FACILITYNAME((ICookNuclearPlantUnit1DOCKETNUMBER(2)YEARLERNUMBER(5)seaveNNAI.NVMEIIRev(sloN~NVMee/IPACK(3)TEXT///morototcoitroeor/od.Vtooddroooo/HRCForm355A'I/I)))050003159401400020F03ConditionsPriortoOccurrenceUnitOneinMode1at100percentpower;UnitTwoinModeOneat68percentpower.DescritionofEventOnJanuary6,1995itwasdiscoveredthatTechnicalSpecificationsurveillance4.11.2.1.2forUnitsOneandTwoGlandSealExhaustweeklygaseouseffluentgrabsamplewasnotcompletedfortheperiodofDecember17throughDecember25,1994.TechnicalSpecificationTable4.11-2(C)requiresthegrabsampletobetakenonaweeklybasis.SurveillancerequirementsaretrackedusingtheNuclearTrackingSystem(NTS)surveillancetrackingsystem.Aseachlineitemrepresentingasurveillancerequirementiscompleted,theresponsibleindividual"signsoffH(initials)theform.Inadditiontotheweeklygaseousgrabsample,TechnicalSpecification4.11.2.1.2,Table4.11-2(C)requiresamonthlysurveillanceontheGlandSealExhaustforparticulate,iodineandtritium.Theinvolvedindividualwasawarethatthismonthlysurveillancehadbeencompletedthepreviousweek.OnDecember23,1994,whentheweeklygaseousgrabsamplewasdue,theindividualmistakenlymarkedthelineitemforthegaseoussampleasRNotApplicable"(N/A)ontheNTSform,believingthatthelineitemrepresentedthemonthlysurveillanceforparticulate,iodineandtritium.CauseofEventThi..v.ntisattributabletopersonnelerror.Theknowledgethatthemonthlysurveillancehadbeencompletedthepreviousweekresultedintheresponsibleindividualexhibitingalackofattentiontodetail.TheindividualfailedtoreadtheNTSformcarefully,andsubsequentlymarkedtheformincorrectly.AnimportantcontributingfactortothiserrorwastheambiguityoftheNTSscheduleformforChemistry.TheformatfailedtoclearlydefinesurveillancefrequenciesandtheTechnicalSpecificationrequire(Rentwhichthesamplingfulfilled.Inaddition,theformcontainedtasksunrelatedtoTechnicalSpecificationsurveillancerequirements.Alsocontributingtothiseventwasthelackoftimelyreviewofthecompletedsurveillancesfortheperiodinquestion.Supervisorypersonnelwerenotavailabletoreviewthecompletedpaperworkpriortotheexpirationofthegraceperiodforthesurveillance.NRCForot358A(585)

NRCFORM35SA(549)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONIAPPROVED0MBNO.3)50410SEKPIRESls/30/92ESTIMATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:508)HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENTBRANCHIP430).U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555,ANDTOTHEPAPERWORKREDUCTIONPROJECT131504104).OFFICEOFMANAGEMENTANOBUDGET,WASHINGTON.DC20503.FACILITYNAME(1)CookNuclearPlantUnit1DOCKETNUMBER(2)LERNUMBER(5)YEAR(Trs>SEOUSNTIAL@>AEYISIONIIUMSSIIS.OIIUMSIIPAGE(3)TGCT/IImoressrsselsss)O/red,useeddr)iooslllRCForm3SSA's/(I))o5ooo3159401400030F03AnalsisofEventThiseventisbeingreportedinaccordancewith10CFR50.73(a)(2)(i)(B)asoperationprohibitedbytheplant'sTechnicalSpecifications.TechnicalSpecification4.11.2.1Table4.11-2(C)requirestheGlandSealExhaustgaseouseffluenttobesampledandanalyzedonaweeklybasis.DuringthemonthofDecember1994,noabnormaloperationalactivitiesoccurredthatwouldhavecausedanalterationinthenormalnuclidecompositionofeitherunits'landSealExhausteffluent.Areviewofthegaseoussamplesobtainedbeforeandafterthiseventindicatednounusualnuclidespresent.Inaddition,theresultofthesampleanalysesforparticulate,iodineandtritiumwerereviewedfortheperiodspriortoandafterthemissedgaseoussample,andnounusualnuclideswerepresent.Itwasconcludedthatthemissedsurveillancecreatednosafetyhazard,norwasthehealthandsafetyofthepublicjeopardizedatanytime.CorrectiveActionTheNTSsurveillanceschedulesheethasbeenmodifiedusinghumanfactorprinciples.Previously,theformhadcontainedentriesbothforTechnicalSpecificationrequiredsurveillancesandadministrativetasks.Tolessenthepotentialforconfusion,theadministrativetaskshavebeenremovedandtheNTSscheduleformnowcontainsonlyTechnicalSpecificationrequiredsurveillances.Theformathasalsobeenrevisedtoorganizetheinformationfortherequiredsurveillancesinaconsistentandobviousmanner.TheChemistryDepartmenthasestablishedapolicyconcerningtheuseof"N/A"whichmakesitclearthatitsuseisnolongeracceptableontheNTSsurveillancescheduleform.TheproceduregoverningtheuseofNTShasbeenrevisedtoreflectthisclarification.Staffbriefingsontheprocedurechangeshavebeencompleted.Personnelresourceshavebeenreallocatedtobeavailableonatimelybasistoreviewfinishedsurveillancesforcompletenessandaccuracy.PreviousSimilarEvents315/94-012316/93-010316/93-002315/92-013316/91-003FailedComonentIdentificationNoneNRCForm3SSA(549)