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ACCESSION NBR:9307020211 DOC.DATE: 93/06/24 NOTARIZED: NOFACIL:50-275 Diablo Canyon Nuclear Power Plant, Unit 1, Pacific Ga

AUTH.NAME AUTHOR AFFILIATIONSISK,D.P. Pacific Gas & Electric Co.RUEGERFG.M. Pacific Gas & Electric Co.

RECIP.NAME RECIPIENT AFFILIATION

DOCKET ¹05000275

SUBJECT: LER 92-029-01:on 921023,fuel handling bldg activities foundin noncompliance w/TS 3.9.12 due to personnel error.Lamacoids will be installed for SFP bridge & FHB cranesinstructing personnel re notification.W/930624 ltr.

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EG ILE 02FILE 01

L ST LOBBY WARDNSIC MURPHY,G.ANUDOCS FULL TXT

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0

Pacific Gas and Electric Company 77 Beale Street, Room1451P.O. Box 770000San Francisco, CA 94177415/973-4684Fax 415/973-2313

Gregory M. Rueger

Senior Vice President and

General Manager

Nuclear Pom;er Generation

June. 24, 1993

PGEE Lett'er No. DCL-93-160

U.S. Nuclear Regulatory CommissionATTN: Document Control DeskWashington, D.C. 20555

Re: Docket No. 50-275, OL-DPR-80Docket No. 50-323, OL-DPR-82Diablo Canyon Units 1 and 2

Licensee=Event Report 1-92-029-01Fuel Handling Building Activities in Noncompliance With TechnicalSpecification 3.9. 12 Due to Personnel Error

Gentlemen:

PGLE is submitting the enclosed revision to Licensee Event Report (LER)1-92-029 pursuant to 10 CFR 50.73(a)(2)(i)(B) concerning fuel handlingbuilding activities conducted with the ventilation system not configuredin accordance with Technical Specification 3.9. 12. This revision isbeing submitted to report the results of PGLE's root causeinvestigation, corrective actions for this event, a minor clarificationin the safety analysis, and minor editorial comments in the othersections of the LER.

This event has in no way affected the health and safety'of the public.

Sincerely,

„A.Gregory N. Rueger

CC: Bobbie H. FaulkenberryAnn P. HodgdonNary H. HillerSheri R. PetersonCPUCDiablo DistributionINPO

DC2-93-TP-N015

Enclosure

6152S/85K/ALN/2246

r~~nnoc.'))3070202 i 1 930624PDR ADOCK 05000275S PDR

.ICENSEE EVENT REPORT (LEllll

FACIUTYNAMEIII ~

DIABLO CANYON UNIT 1

DOCKET NUMBER 21 PACE 3

0 5 0 0 0 2 7 5 1" 7

TITLEI41 FUEL HANDLING BUILDING ACTIVITIES IN NONCOMPLIANCE WITH TECHNICAL SPECIFICATION 3.9.12DUE TO PERSONNEL ERROR

EVENT DATE (Sl

MON DAY

10 23 92

LGl NUMBER (Sl

6EOUENTIALNUMBER

REVISIONNUMBER

REPORT DATE (71

DAYMON

9392 — 0 2 9 — 0 1 06

OTHER FACILITIES INVOLVED (a)DOCKET NUMBER ISI

0 5 0 0 0 3 2 3

0 5 0 0 0

FACIUTYNAMES

DIABLO CANYON UNIT 2

OPERATiNGMODE (9)

THIS REPORT IS SUBMITTED PURSUANT To THE REQUIREMENTS OF 10 CFRI (11)

POVERLEVEL 000 X 10 CFR 50.73 a 2 I B

OTHER

(Specify in Abstract beloH and in text, NRC Form 366A)

UCENSEE CONTACT FOR THS LER 112lT E PHON NVH R

DAVID P. SISK, SENIOR REGULATORY COMPLIANCE ENGINEER

COMPLETE ONE UNE FOR EACH COMPONENT FAILURE DESCRIBED IN TIES REPORT 113l

AREA CODE

805 545-4420

CAUSE SYSTEM COMPONENT MANUFACTVRER

REPORTABLETo NPRDS

CAUSE SYSTEM COMPONENT MANVFACTURER

REPORTABLE'o

NPRDS

SUPPLGVIENTAL REPORT EXPECTED (141

YES (if yes, complete EXPECTED SUBMISSION DATE) [ X i NO

ABSTRACT (16)

EXPECTEDSUBMISSIONDATE (15)

MONTH DAY YEAR

On March 11, 1993, with Unit 2 in Mode 6 (Refueling), during an operator walkdown,a Senior Reactor Operator discovered that fuel handling building (FHB) Exhaust FanE-5 was inoperable. While reviewing this condition, PG&E determined that a dummy

fuel assembly was moved in the spent fuel pool (SFP) on March 10, 1993, with theFHB ventilation system (FHBVS) not in the iodine removal mode. TechnicalSpecification (TS) 3.9. 12 was not met when loads were moved over the SFP with theoperating exhaust fan not aligned for iodine removal.

On March 18, 1993, while reviewing the March 10, event, PG&E questioned theprevious interpretation of the definition of load movement in TS 3.9. 12. PG&E

determined that previous movement of the spent fuel assembly handling tool onOctober 23, 1992, did not meet the requirements of TS 3.9. 12.

PG&E has determined that the root cause of both events is personnel error. TheOctober 23, 1992, event was due to inadequate communication within the controlroom. During the events on March 10 and 11, 1993, the shift foreman (SFM) was notaware that one train of the FHBVS was inoperable due to a bus outage. A lamacoidwill be installed at both the SFP bridge and FHB cranes instructing personnel tocontact the SFM immediately prior to moving loads over the SFP to verify properFHBVS alignment. In addition, an operations incident summary will be issued.

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DIABLO CANYON UNIT 1

DOCKEt NIPISER (2)

05 0 0 0 2 7 5 92

LER NUHSER 6

029

INVISONNUMBER

0 1 2-" 7

I. Plant Conditions

Unit 1 was in Mode 6 (Refueling) at 0 percent power„ during the October 23,1992, event and Unit 2 was in Mode 6 at 0 percent power during the March 10

and 11, 1993, events.

II. Descri tion of Event

A.

B.

Summary:

1. March 10 and 11, 1993, Dummy Fuel Assembly and Handling ToolMovement Events

On March 10, 1993, during the Unit 2 fifth refueling outage(2R5), a load (dummy fuel assembly (DF)(FHM)) was moved about inthe spent fuel pool (SFP)(DB), while the fuel handling building(ND) ventilation system (FHBVS)(VG) was not in the iodineremoval mode as required by Technical Specification (TS) 3.9. 12,"Fuel Handling Building Ventilation System." On March 11, 1993,the spent fuel assembly (SFA) handling tool (DF)(FHM) waspositioned over the dummy fuel assembly while the FHBVS was notin the iodine removal mode.

2. October 23, 1992, SFA Handling Tool Movement Event

While reviewing the TS applicability of the March 10 event, PGSE

reevaluated the definition of a load with respect to TS 3.9. 12.As a result of this reevaluation, PGSE determined that onOctober 23, 1992, during the Unit 1 fifth refueling outage(1R5), movement of the SFA handling tool over the SFP, withFHBVS Exhaust Fan E-5 (VG)(FAN) cleared and FHBVS Exhaust FanE-6 (VG)(FAN) not in the iodine removal mode, was a violation ofTS 3.9. 12 requirements.

Background:

Final Safety Analysis Report (FSAR) Update Section 9.4.4.2 indicatesthat the iodine removal mode of FHBVS operation is required when thereis a potential for radioactive particulates and/or radioactive gasesin the exhaust air of the FHB. The iodine removal mode routes allexhaust air through roughing filters (VG)(FLT), high efficiencyparticulate air filters (HEPA)(VG)(FLT), and activated charcoal(VG)(ADS) filters. The system has redundancy "for all

essential,'onstatic

components. When not manually selected, the iodine removalmode of ventilation is automatically initiated by a radiationdetector.

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C.

TS 3.9. 12 requires that, with one FHBVS exhaust fan inoperable, fuelmovement within the SFP or crane operations with loads over the SFP

may proceed provided the operable exhaust fan is in the iodine removalmode. TS 3.9. 12 also requires that, with no FHBVS exhaust trainoperable, movement of fuel or crane operation with loads over the SFP

be suspended.

Event Description:

On March 10, 1993, at 0100 PST, a tailboard was'eld to discuss themovement 'of the dummy fuel assembly from the Unit 2 new fuel elevator(DF)(FHM) to the upender (DF)(FHM). The shift foreman (SFM) had beenpreviously contacted and he confirmed that the FHBVS alignment wasacceptable for the planned activity. The FHBVS was aligned in thenormal, non-iodine removal mode.

On March 10, 1993, at 0130 PST, FHB pressure was verified to be

approximately negative 0. 175-inch H,O, greater than the negative1/8-inch (0. 125") H,O required by TS 3.9. 12. At 0200 PST, the dummy

fuel assembly was moved from its SFP storage rack (DB)(RK) location tothe new fuel elevator using the SFA handling tool.

On March 11, 1993, at 0600 PST, the SFA handling .tool was posi-tionedover the dummy fuel assembly. At the same time the refueling senior,reactor operator (SRO) was walking down the equipment necessary forfuel handling operations. The refueling SRO discovered that the FHBVS

Exhaust Fan E-5 inlet vane was failed open (the fan was inoperable dueto the scheduled Bus F (EB)(BU) outage that began on March 8, 1993);and, although, the TS required negative pressure was met, the operatingFHBVS exhaust fan was not in the iodine removal mode. The FHBVS wasin the normal mode with Exhaust Fan E-4 (VG)(FAN) operating. WithExhaust Fan E-5 inoperable, TS 3.9. 12, Action a. was applicable;therefore, the FHBVS should have been in the iodine removal mode priorto moving the SFA handling tool over the SFP. Since the FHBVS was

aligned to the normal mode during the dummy fuel assembly movement onMarch 10 and the SFA handling tool movement on March 11, therequirements of TS 3.9. 12 were not met.

The FHBVS was placed in iodine removal mode and the SFA handling toolwas secured per direction from the SFM and refueling SRO. SystemEngineering personnel checked the ventilation system to confirm theoperability of the iodine removal function and determined it to beacceptable. The dummy fuel assembly was moved to the new fuelelevator and .the SFA handling tool was returned to its bracket.

On March 18, 1993, while reviewing the March 10 and 11, 1993,conditions, PGKE questioned the previous interpretation of thedefinition of load movement in TS 3.9. 12. PGEE concluded that anyload that required use of the FHB crane (DF)(FHM) was a load per

6152S/85K

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TEXT (17)

DIABLO CANYON UNIT 1

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LER NUMBER 6SCOVENAAL

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029

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TS 3.9. 12. A review of operating history identified that, onOctober 23, 1992, the SFA handling tool was lifted with the crane forcleaning and inspection. PG&E conservatively determined that thismovement of the SFA handling tool also was movement of a load and therequirements of TS 3.9. 12 were not met at that time.

D. Inoperable Structures, Components, or Systems that Contributed to theEvent:

None.

Dates and Approximate Times for Hajor Occurrences:

I

I

2.

3'.

October 23, 1992: Event date. The SFA handling toolwas lifted with the FHB crane forinspection, with FHBVS Exhaust FanE-5 cleared and FHBVS Exhaust FanE-6 not in the iodine removalmode.

March 10, 1993, at 0130 PST: FHB pressure was verified byReactor Engineering to be greaterthan negative 1/8-inch (0. 125M)

H,O (approximately negative0. 175-inch H,O).

March 10, 1993, at 0200 PST: Event date. The dummy fuelassembly was moved from SFP racklocation N-37 to the new fuelelevator using the SFA handlingtool. TS 3.9. 12 was not met sincethe FHBVS was not in the iodineremoval mode.

4.

5.

March ll, 1993, at 0600 PST: Event date/discovery date. TheSFA handling tool was positionedover the dummy fuel assembly.FHBVS Exhaust Fan E-5 wasidentified as inoperable due toBus F outage.

March 11, 1993, at 0615 PST: The FHBVS was placed in iodineremoval mode until the SFA.

'andlingtool was secured.

F. Other Systems or Secondary Functions Affected:

None.

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G. Hethod of Discovery:

On Harch 11, 1993, during an operator walkdown, an SRO discovered thatFHBVS Exhaust Fan E-5 was inoperable. While reviewing this condition,PG&E determined that a dummy fuel assembly was moved in the SFP onHarch 10, 1993, and the SFA handling tool on Harch 11, 1993, with theFHBVS not in the iodine removal mode.

On March 18, 1993, while reviewing the Harch 10 "and 11, 1993,conditions, PG&E questioned the previous interpretation of thedefinition of load movement in TS 3.9. 12. PG&E conservativelydetermined that movement of the SFA handling tool on October 23,1992, also was movement of a load and the requirements ofTS 3.9. 12 were not met at that time.

H.

III. Cause

Operator Actions:

On discovery of the Harch 11, 1993, FHBVS condition, Operations placedthe FHBVS in the iodine removal mode. There were no additionaloperator actions related to the October 23, 1992, event.

Safety System Responses:

None required.

of the Event

A. Immediate Cause:

The immediate cause for both the event on October 23, 1992, and theHarch 10 and 11 events is movement of a load over the SFP without an

FHBVS train in the iodine removal mode.

B. Root Cause:

The root cause of the events on Harch 10 and 11, 1993, was personnelerror (cognitive), in that there was inadequate communication withinthe control room between the SFH and the outage assistant SFH.

The root cause of, the event on October 23, 1992, was also personnelerror (non-cognitive), in that the SFH was not aware that one train ofthe FHBVS was inoperable due. to a scheduled vital Bus F outage.

IV. Anal sis of the Event

,The FSAR Update analyzes a fuel handling accident in which a fuel assemblyis dropped on another fuel assembly. In analyzing the potential for otherfuel handling accidents for comparison with FSAR Update cases, it isconsidered far more credible that a fuel assembly could be damaged by being

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V.

dropped against a sharp edge rather than sustaining damage while in thestorage rack due to a dropped load. Therefore, the FSAR Update expected caseassumption of 17 damaged rods would conservatively bound the potentialsource term from a dropped insert handling tool.

The FHBVS has two modes of operation. The normal mode exhausts air throughroughing and HEPA filters and Fan E-4 without flowing through a charcoalfilter, and the iodine removal mode exhausts air through the roughing and

HEPA filters and either Fan E-5 or E-6, with air flow also through charcoalfilters. When not manually selected, the iodine removal mode of ventilationis automatically initiated by a radiation detector (IL)(NON). Sincenegative building pressure was maintained throughout the event, Unfilteredleakage from the building would not have occurred. If an accident hadoccurred, the FHB radiation detector would have detected any significantiodine activity and the FHB exhaust air flow would have automaticallyshifted to the iodine removal mode. Therefore, the radiologicalconsequences of a load drop accident would have been conservatively bounded

by the FSAR Update expected case fuel handling accident.

The resulting postulated fuel rod failures provide the source term fordetermining the potential site boundary dose for the March 10 and 11 and

October 23 events. During the March 10 and 11 and the October 23 events,the dummy fuel assembly and the SFA handling tool, respectively, were nothandled over fuel, and.if dropped would not have impacted any fuelassemblies. Thus, had an accident occurred during the described events, theresulting plant and site boundary exposures would be bounded by accidentspreviously analyzed in the FSAR Update.

Therefore, the health and safety of the public were not adversely affectedby these events.

Corrective Actions

A. Immediate Corrective Actions:

B.

For the March 10 and 11, 1993, events, the FHBVS was placed in theiodine removal mode. There were no immediate corrective actions forthe October 23, 1992, event.

Corrective Actions to Prevent Recurrence:

2.

Lamacoids will be installed for the SFP bridge and FHB cranesinstructing personnel to contact the SFH immediately prior'omoving loads over the SFP to verify proper FHBVS alignment.

An operations incident summary will be issued to emphasize -theimportance of proper FHBVS alignment for FHB load movementactivities.

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VI. Additional Information

A. Failed Components:

None.

B. Previous Similar Events:

None.

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