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10CFR50,73 j

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IDocket No. 50 461(

U.S. Nuclear Regulatory Commissinn |Document Control Desk *

Wshington, D.C. 20555 i:

Subject: Clinton Power Station . Unit 1' '.,

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Licensee Eventlecort No. 89@i,QQ'

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Dear Sir: ,

Tlease find enclosed 1Acenree Event Report No, 89-034 00:Lack of. Training. Personnel Irror'and Inadecuagg Con.munieggiqng,.) Ray 3 ,

,(n Failure to Verify Precess Radj,gri.on.. Monitor Ooerobility and to Meet [Iechnical Soecification Recuirements, This report is being submitted in !accordance with the requirements of 10CT1tSO.73. ;'

!Sincerely yours,

5 ). W

D. L. HoltzscherActing Manager . -

Licensing and Safety

TSA/kra ;

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' Enclosure [:

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L NRC Region III, Regional Administrator i

INFO Records Center ;

Illinois Department of Nuclear SafetyNRC Clinton Licensing Project Manager

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ABSTBAC.I {

On October 4, 1989, a Radiation Protection Shift Supervisor (RPSS);

discovered that the in service Station Heating, Ventilatinh and Airu

Conditioning (HVAC) Exhaust Stack Process Radiation Monitor (PRM),j ORIX PR001 had not been verified as operable. This resulted in a failure| to meet the Limiting Condition for Operation for Technical Specification| (TS) 3.3.7.12. This TS requires that one Station HVAC Exhaust Stack PRMi be operable at all times. At 0826 hours, PRM ORIX PR002 was removed from

service and PRM ORIX PR001 was placed in service. The Radiation'

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1 Protection (RP) technician (tech) transferring the monitors did notperform all of the checks required to verify that PRM ORIX PR001 was

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operable after piccing it in service. Specifically, the RP techperformed a channel check on the monitor but did not verify flow.Therefore, the PRM was inoperable. This event was caused by lack oftraining, personnel error and inadequate communications. The RP tech wasnot fully qualified and the RPSS failed to direct the RP tech to useapplicable procedures when placing PRM ORIX FR001 in service. Corrective

| actions include reminding appropriate RP personnel of the need to use and| follow procedures, and counselling RP Shift Supervisors on the need to

ensure techs are qualified and on the need to review and statusactivit.ies affecting RP.

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!DESCRIPTION OF EVENI I

On October 4, 1989, t.he plant was in Mode 1 (POWER OPERATION) and thereactor [RCT) was at eighty five percent power. On the morning ofOctober 4, 1989, Chemistry personnel contacted the Rad!ation Protection

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(RP) technician assigned as the Area / Process Radiation Monitor (AR/PR) |operator and requested that Radiation Protection personnel remove the in-service Station Heating, Ventilation, and Air Conditioning (HVAC) ExhaustStack Process Radiation Monitor (PRM) [IL), ORIX PR002, from service andplace the redundant monitor [ MON), ORIX PR001, in service. This monitor ;

"transfer is performed weekly to ensure the monitors are used equally andto enable Chemistry personnel to replace the ffiters (FLT) in the ;monitors in accordance with Technias,1 Sp9eification Table 4.3.7.12 1.

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The technician assigned as the AR,'PR operator had rot previeur',y ,

performod a monitor exchange and therefore requastod direut'on frosn the :

c'ay shif t 'u.diation Protectica Shif t Supetvisor (RPSP.,. The RPSS jexplained to the technician the wethodology for removing monitor ,

ORIX PR002 from service ano placing it in "starJbya and the et.hodology.for placing redundmot monitor ORIX PR001 in service ('' normal") . The RTSSdirected the technician to note the coepletion of the honLter exchange in i

the RP log. The exchange van cogleted at 0826 hours. After completingthe exchange, the RP techn! clan performt,d s channel [CHA) check onmonitor ORIX PR001 by comparing its indication with the last indicationof inonitor ORIX PR002. This check verified that monitor ORIX PR001 wasin service and was providing accurate data to the Central Control

Terminal (CCT) in the RP office.'At 1944 hours, during review of completed surveillance procedure 9911.24,

"AR/PR Shiftly/ Daily Surve111ances", the second shift RPSS noted that notall checks required to verify operability of monitor ORIX PR001 were ,

doc'iment ed. :

The RPSS di'tected the second shift RP technician assigned as the AR/PR ,

operator to perform surveillance 9911.24 to verify that monitor ORIX. I

PR001 was operable. In accordance with surveillance 9911.24, the RPtechnician performed a channel check and a sample flow indicator [FI)check. Surveillance 9911.24 was completed at 2000 hours with i

satisfactory results. (A communications check, which is required to beperformed once each shift, was documented as having been completed at

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0741 hours and 1555 hours.) 6

Since the checks to verify the operability of monitor ORIX PR001 were notperformed within one hour of placing monitor ORIX PR001 in service, theLimiting Condition for Operation (LCO) for Technical Specification3.3.7.12 was not met. Technical Specification 3.3.7.12 requires that onestation HVAC exhaust PRM be operable at all times. Operability of ORIX.PR001 was not verified until 2000 hours on October 4, 1989,

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Technical Specification 3.3.7.12 permits a Station INAC Exhaust Stack PRM'

to be placed in an inoperable status for up to one hour for the purpose .

of performing sutveillances. Monitor ORIX PR001 was placed in service at i

0826 hours, therefore the LCO for Technical Specification 3.3.7.12 wasnot met from 0926 hours until 2000 hours on October 4, 1989.

Ne automatic or manually initiated safety system responses were necersaryto place the plant in a safe and stable condition. No other eyvipent o;conponents were inoperabic at the start of this event such that their

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inoperable condition contributed to this event. |

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The cause of the event is attmibuted to inck of training, personnel artorand inadequatc comtaunications,

g Tha RP technician assigned as the AR/PR operator was not fully qualifiedI. for that posit 3on becauce he had not completed all of the required,

training. He was horever, considered to have sufficient experience andto have demonstrated a level of proficiency sufficient to perform AR/PRoperator activit.as under the direct supervision of fully qualifiedi

personnel.

i The RPSS failed to direct the RP technician to use the proceduresgoverning the operation and testing of the AR/PR monitors when removingmonitor ORIX PR002 from service and placing monitor ORIX PR001 inservice. Radiation Protection procedure 7410.75, ' Operation of DigitalAR/PR Monitors" provides instructions for removing monitors from service,for starting monitors, and for returning monitors to serrice.Surveillance procedure 9911.24 provides instructions for performing thechecks required to verify monitor operability. Neither of theseprocedures was utilized when transferring the Station INAC Exhaust StackPRMs and verifying their operability.

Contributing to the failure to meet the LCO for Technical Specification3.3.7.12 was the lack of involvement of the RPSS in the monitor transferprocess. The RPSS was aware that the monitor transfer was to occurbecause the evolution had been discussed at the Operations shift

I turnover. However, the RPSS did not discuss the monitor transfer with RP

| personnel at the RP shift turnover. The RPSS did not follow up to ensure' the monitor transfer had been completed satisfactorily.

In addition to performing AR/PR operator duties, the RP technician wasacting as the on duty RP office technician performing routine RP officework. The RP technician was required to perform the additional dutiesbecause of the high volume of routine RP office work required to beperformed in the first few hours of each shif t. Performing the duties of

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both positions adversely affected the RP technician's performance of hisAR/PR operator duties.

Procedure 7410.75 was reviewed following the event and it was determinedthat even if the applicable proceditres had been used when removingmonitor OR1X PR002 from service and placing monitor ORIX PR001 in '

service, all of the checks required to verify operability may not havebeen performed. Procedure 7410.75 did not address the requirement to

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perform surveillance 9911.24 when placing AR/PR monitors in service.Procedure 7410.75 did not require that the Operatiene Shif t Supervisy r t e-

notified of monitor operability onu. the AR/PR monitors reyttired te acetTechnical Specifications were placed in service. Operationa petronnel 'a

were natified that n.onitor ORIX PR001 was placed in service and that. the,

monitor was op3 rating properly. Operations personnel believed that when -

RP pers onnel stated tt'at monitor ORIX PR001 was operating properly , i

checks required to meet the requirements of Technical Specification3.3.7.12 had been completed with aatisfactory rvsults.

G,RRECTIVE ACTIQNf3

Radiation Protection Shift Supervisors have been counselled on the need I

to ensure that RP technicians are fully qualified for the positions to ,

which they are assigned. The Radiation Protection Shift Supervisors werealso ceunselled on the need to review the Daily Activity Schedule forupcoming activities which involve or affect Radiation Protection, and on '

the need to discuss the status of these activities at the RP shiftturnover meetings. ,

A night order was issued to appropriate Radiation Protection personnelregarding: the need to use procedures, particularly when placingmonitors in service from a " standby" condition; the checks required to beperformed in accordance with surveillance 9911.24; and the requirement to '

notify Operations personnel when changing the status of monitors meetingTechnical Specification requirements.

A night order was issued reminding appropriate Radiation Protectionpersonnel that whea assigned to a position it is their responsibility toensure that they meet the requirements of that position prior to assumingany additional duties or positions. This ensures that requirements aremet, while at the same time providing for flexibility and reassignment of

I personnel.

Proceduren 7410.75 and 9911.24 have been revised to include the stepsrequired to be completed to verify AR/PR monitor operability, and toinclude a step requiring that operations personnel be notified when amonitor is placed in service and when surveillance procedure 9911.24 hasbeen satisfactorily completed.;

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ANALYSIS OF EVENT

This event is reportable in accordance with the provisions of ;

10CFR50.73(a)(2)(1)(B) due to operation prohibited by Technical Ii

Specifications. The 140 for Technical Specification 3.3.7.12 was not metfrom 0926 hours until 2000 hours on October 4, 1989.

Aasessment of the nuclear safety consequences and inp11 cations of this i

event indicated that this event was not safety significant for existing ,

or other p?. ant conditions. Cumpletion of survet11ance 9911.24 withsatisfactory results indies.tes thet.sonitor ORIX.P3001 ess a.ccuratelymonitoring effluent through the Common HVAC Stack,

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liu 88 020 00 discusse(. ttn failure to ensure that a liquid efaturnt l',, .

1roonitor vr.e placed 1,1 an operat,le status prioY to bi-ing dsclaredoperable. The cause cf this event wars vague coinanications bacween ;

Operations and Rad 16 tion Protection ;eis.onnel regarding whether theannitor was in "normala or " standby'.

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For further information regarding this event, contact D. W. Miller,Director Plant Radiation Protection, at (217) 935 8881, extension 3313.

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